autism spectrum disorders in dsm-5ihspta.weebly.com/uploads/3/9/1/4/39140819/dsm-5...or verbal and...

J ILL FODSTAD, PH.D. , HSPP, BCBA -D A S S I S TA N T P R O F E S S O R O F C L I N I C A L P SYC H O LO GY

D E PA RT M E N T O F P SYC H I AT RY I U S C H O O L O F M E D I C I N E

J F O D S TA D @ I U H EA LT H .O R G

Autism Spectrum Disorders in DSM-5

September 18, 2015 Talk and Slides by Jill Fodstad, Ph.D., HSPP, BCBA-D (2015)

Objectives

Have a basic understanding of the history behind autism

Recognize the changes from DSM-IV-TR to DSM-5 diagnostic criteria for Autism Spectrum Disorder

Become familiar with new diagnostic specifiers

Become familiar with new severity ratings

Talk and Slides by Jill Fodstad, Ph.D., HSPP, BCBA-D (2015)

Where it All Began … Sort Of?

Nervous Child 2:217-250, 1943 Talk and Slides by Jill Fodstad, Ph.D., HSPP, BCBA-D (2015)

Where It All Began … Sort Of?

1944 Talk and Slides by Jill Fodstad, Ph.D., HSPP, BCBA-D (2015)

Diagnostic Criteria for Autism through the DSMs

• DSM-I (1952) and DSM-II (1968) • Schizophrenic reaction, childhood type

• DSM-III (1980) • Infantile autism • Child onset pervasive developmental

disorder

• DSM-III-R (1987) • Autistic Disorder • PDD-NOS

• DSM-IV (1994) and DSM-IV-TR (2000) • Autistic Disorder • Asperger’s Disorder • PDD-NOS • Childhood Disintegrative Disorder • Rett Syndrome

Take-home point: DSM categories are often consistent with the available research at the time (the good, the bad, and the ugly)


What Was DSM-IV-TR?

Autistic Disorder

1. Qualitative impairment in social interaction as manifested by at least one of the following:

a) Marked impairment in use of nonverbal behaviors

b) Failure to develop peer relationships appropriate to developmental level

c) Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people

d) Lack of social or emotional reciprocity

2. Qualitative impairment in communication as manifested by at least one of the following:

a) Language delay

b) Marked impairment in the ability to initiate or sustain a conversation with others

c) Stereotyped and repetitive use of language or idiosyncratic language

d) Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

3. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one

of the following:

a) Encompassing preoccupations with one or more stereotyped and restricted patterns of interest that is abnormal in either

intensity or focus

b) Apparently inflexible adherence to specific, nonfunctional routines or rituals

c) Stereotyped and repetitive use of language or idiosyncratic language

d) Persistent preoccupations with parts of objects

4. Delays or abnormal functioning in at least one area prior to the age of 3 years

a) Social interaction

b) Language as used in social communication

c) Symbolic or imaginative play Talk and Slides by Jill Fodstad, Ph.D., HSPP, BCBA-D (2015)

What Was DSM-IV-TR? Asperger’s Disorder/PDD-NOS

Asperger’s Disorder

C. The disturbance causes clinically significant

impairments in social, occupational, or other

important areas of functioning.

D. There is no clinically significant general

delay in language e.g., single words used by

age two years, communicative phrases used

by age three years).

E. There is no clinically significant delay in

cognitive development or in the

development of age-appropriate self-help

skills, adaptive behavior (other than in social

interaction), and curiosity about the

environment in childhood.

F. Criteria are not met for another specific

pervasive developmental disorder or

schizophrenia.

PDD NOS

The essential features of PDD-NOS are

severe and pervasive impairment in the

development of reciprocal social interaction

or verbal and nonverbal communication

skills;

and stereotyped behaviors, interests, and

activities.

The criteria for Autistic Disorder are not met

because of late age onset; atypical and/or

sub- threshold symptomatology are present.

This category should be used when there is a

severe and pervasive impairment in the

development of reciprocal social interaction

or verbal and nonverbal communication

skills, or when stereotyped behavior,

interests, and activities are present, but the

criteria are not met for a specific Pervasive

Developmental Disorder.


What is DSM-IV-TR? Rett’s Syndrome/CDD

Rett’s Syndrome

A. All of the following:

• apparently normal prenatal and perinatal

development

• apparently normal psychomotor

development for the first 5 months of life

• normal head circumference at birth

B. Onset of all of the following after the period

of normal development

• deceleration of head growth (5-48months)

• loss of purposeful hands movements (5-30

months) and development of stereotypic

hand movements (i.e., hand-wringing or

washing)

• loss of social engagement

• poorly coordinated gait or trunk movements

• severely impaired expressive and receptive

language development

Childhood Disintegrative Disorder

A. Apparently normal development for at least

the first 2 years of life

B. Clinically significant loss of skills (before age

10 years) in at least 2 of the following:

expressive or receptive language

social skills or adaptive behavior

bowel or bladder control

play

motor skills

C. Abnormalities of functioning in at least 2 of

the following:

• social interaction

• communication

• restricted, repetitive, and stereotyped

patterns of behavior, interests, and activities,

D. The disturbance is not better accounted for

by another specific PDD or by schizophrenia


Why was it changed?

APA intends the DSM to reflect most current research and practice

Last revision – 2000

Confusion and inconsistent application of previous PDD diagnoses


Why was it changed?

Improve sensitivity and specificity

Provide more accurate and descriptive information (Specifiers) Co-existing conditions and genetic or medical diagnoses

Severity level (based on level of supports)

Intellectual functioning

Language level

Increased access to services


DSM-IV TR DSM-5

Pervasive Developmental Disorder

5 Diagnoses Autistic Disorder

Asperger’s Disorder

PDD-NOS

Rett’s Syndrome

Childhood Disintegrative Disorder

3 “categories” of symptoms Communication

Social Interaction (2/4)

Restricted and Repetitive Behaviors

Autism Spectrum Disorder

1 Diagnosis Autism Spectrum Disorder

2 “categories” of symptoms Social Communication (3/3)

Restricted and Repetitive Behaviors (2/4)

Changes


DSM-IV TR DSM-5

Pervasive Developmental Disorder

No indication about sensory differences

Language delay criteria

Must be present before age 3 years

Autism Spectrum Disorder

Added hyper- or hypo-reactivity to sensory input (to RRB)

Delay in language removed

Present in the early developmental period but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life

Changes


A. Persistent deficits in social communication and social interaction

across multiple contexts, manifested by the following, currently or by history

(examples are illustrative not exhaustive; see text):

1. Deficits in social-emotional reciprocity; ranging, for example, from abnormal

social approach and failure of normal back-and-forth conversation; to reduced sharing

of interests, emotions, or affect; to failure to initiate or respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction,

ranging, for example, from poorly integrated verbal and nonverbal communication; to

abnormalities in eye contact and body language or deficits in understanding and use

of gestures; to a total lack of facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for

example, from difficulties adjusting behavior to suit various social contexts; to

difficulties in sharing imaginative play or in making friends, to absence of interest in

peers.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth

Edition, (Copyright © 2013). American Psychiatric Association. All rights reserved.

B. Restricted, repetitive patterns of behavior, interests, or activities, as

manifested by at least two of the following, currently or by history

(examples are illustrative, not exhaustive; see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech

(e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia,

idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized

patterns of verbal or nonverbal behavior (e.g., extreme distress at small

changes, difficulties with transitions, rigid thinking patterns, greeting rituals

need to take same route or eat same food every day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus

(e.g., strong attachment to or preoccupation with unusual objects, excessively

circumscribed or perseverative interests).

4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory

aspects of the environment (e.g., apparent indifference to pain/temperature,

adverse response to specific sounds or textures, excessive smelling or

touching of objects, visual fascination with lights or movement).



C. Symptoms must be present in the early developmental

period (but may not become fully manifest until social

demands exceed limited capacities; or may be masked by

learned strategies in later life).

D. Symptoms cause clinically significant impairment in

social, occupational, or other important areas of current

functioning.

E. These disturbances are not better explained by intellectual

disability (intellectual developmental disorder) or global

developmental delay. Intellectual disability and autism spectrum

disorder frequently co-occur; to make comorbid diagnoses of

autism spectrum disorder and intellectual disability, social

communication should be below that expected for general

developmental level.



Note: Individuals with a well-established

DSM-IV diagnosis of autistic disorder,

Asperger’s disorder, or pervasive

developmental disorder not otherwise

specified should be given the diagnosis

of autism spectrum disorder.



DSM-5 Criteria

C. Symptoms must be present in the early developmental period (but may not fully manifest until social demands exceed limited capacities, or may be masked by learned strategies later in life)

D. Symptoms cause clinically significant impairment

E. Disturbances not better accounted for by intellectual disability or global developmental delay.


Diagnostic Specifiers

DSM-5 299.0 Autism Spectrum Disorder Level of Support required (i.e., Severity) With or Without intellectual impairment With or Without language impairment Associated with a known medical or genetic condition or

environmental factor Associated with another neurodevelopmental, mental or behavioral

disorder (e.g., ADHD) With catatonia


Specifier: Level of Support Required

Severity Level

Social Communication Restricted, Repetitive Behaviors

Level 1: “Requiring Support”

• Without supports in place, deficits in social communication cause noticeable impairment

• Difficulty initiating social interactions

• Clear examples of atypical or unsuccessful responses to social overtures

• May appear to have decreased interest in social interactions

• Inflexibility of behavior causes significant interference with functioning in one or more contexts

• Difficulty switching between activities

• Problems of organization and planning hamper independence



Severity Level


Level 2: “Requiring substantial

support”

• Marked deficits in verbal and nonverbal social communication skills

• Social impairments apparent even with supports in place

• Limited initiation of social interactions

• Reduced or abnormal response to social overtures

• Inflexibility of behavior • Difficulty coping with

change • Restricted/repetitive

behaviors obvious to observers & interfere with functioning in variety of contexts

• Distress/difficulty changing focus or action.



Severity Level


Level 3: “Requiring

very substantial

support”

• Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning

• very limited initiation of social interactions

• minimal response to social overtures from others.

• Inflexibility of behavior • Extreme difficulty coping

with change • Restricted/repetitive

behaviors markedly interfere with functioning in all spheres

• Great distress/difficulty changing focus or action.


Additional Changes

Can now have comorbid diagnoses: Language Disorders

Global Developmental Delay (under 5 years old)

Attention-Deficit/Hyperactivity Disorder

Generalized Anxiety Disorder

Axial system eliminated


Sample Diagnosis (DSM-IV-TR)

Axis I: Autistic Disorder (299.0)

Axis II: Intellectual Disability, Mild (317.0)

Axis III: Seizure Disorder (780.39)

Axis IV: school difficulties, sibling conflict

Axis V: GAF = 55


Sample Diagnosis (DSM-5)

299.0 Autism Spectrum Disorder associated with Seizure Disorder:

Currently requiring substantial supports for deficits in social

communication and support for restricted, repetitive behaviors

With accompanying intellectual impairment (Intellectual Disability, Mild: 317.0)

With accompanying language impairment (phrase speech, delays in receptive and expressive communication)

Not associated with any known genetic cause (appointment pending)


New Diagnosis: SCD

Social (Pragmatic) Communication Disorder Children who demonstrate social-communicative impairments

without repetitive behaviors/restricted interests

Thought that this diagnosis will capture some children formerly diagnosed with PDD-NOS

Separate diagnosis to ensure access to services and not lost under “NOS” classification


Intellectual Disability

Replaces the term ‘mental retardation’

Mental Retardation (DSM-IV-TR) Mild (IQ/Adaptive = 50-55 to 70)

Moderate (IQ/Adaptive = 35-40 to 50-55)

Severe (IQ/Adaptive = 20-25 to 25-40)

Profound (IQ/Adaptive ≤ 20-25)

Unspecified (untestable or not yet tested, but suspected)

Global Developmental Delay Children under 5 years old who demonstrate delays in intellectual

development



No longer using IQ scores to determine severity, instead relying on adaptive functioning Mild

Moderate

Severe

Profound

Unspecified (5+ years, untestable or not yet tested)

Remove age of onset prior to age 18 years, now more general statement that onset begins “during the developmental period”


DSM-5Backlash!


No more Asperger’s?

Asperger’s Disorder is no longer a distinct category -

“...identity that represents this pertains to an individuals specific strengths and challenges.”

New diagnostic structure allows for descriptive information to convey these strengths and challenges More individualized for everyone receiving a diagnosis


What does the research say so far?

Studies conducted with initial drafts of DSM-5 criteria created some alarm 39.4% of those with DSM-IV PDDs not meeting DSM-5 criteria

(McPartland et al., 2012)

47.7% of toddlers with PDD failed to meet DSM-5 criteria (Matson et al., 2012)

Young & Rodi (2013) found 57.1% with DSM-IV diagnosis met DSM-5 criteria

Some methodological limitations to these studies High functioning individuals less likely to meet criteria

Failure to meet all 3 social-communication criteria was the most common reason for exclusion


What does the research say so far?

More recent studies look more favorable

46% of children with PDD met criteria under early DSM-5 criteria but improved to 96% with more similar criteria (Mattila et al., 2011)

Removal of age of onset criteria increased sensitivity, especially in high functioning subgroup (Mattila et al., 2011)

Specificity of DSM-5 improved over DSM-IV, especially when data was collected from both parent report and direct observation (Huerta et al., 2012)


What do these changes really mean?

Most individuals with a DSM-IV diagnosis of a PDD will meet criteria for a DSM-5 diagnosis of ASD

Relabeling of Asperger’s Disorder will be difficult for some individuals and families

“Severity specifiers should not be used to determine type or eligibility for services”, hopefully this will be the case

Impact of new Social Communication Disorder remains to be seen


Future Directions

Need to know more about how the new criteria will effect: Those who are already diagnosed

Those who are receiving diagnoses under new criteria

Social (Pragmatic) Communication Disorder

Impact of service delivery

Educational programs

State and Federal programs


What should we tell parents and individuals with ASD?

Your (child’s) diagnosis will most likely not change

School services in Indiana are not anticipated to change because ASD categorization is already in use

Changing a label does not mean the problems no longer exist


Questions?? Email: [email protected]

References

Amir, R. E., Van den Veyver, I. B., Wan, M., Tran, C. Q., Francke, U., & Zoghbi, H. Y. (1999). Rett syndrome is caused by mutations in X-linked MECP2, encoding methyl-CpG-binding protein 2. Nature genetics, 23(2), 185-188.

Asperger, H. (1944). Die „Autistischen Psychopathen” im Kindesalter. European Archives of Psychiatry and Clinical Neuroscience, 117(1), 76-136.

Huerta et al. (2012). Application of DSM-5 criteria for autism spectrum disorder to three samples of children with DSM-IV diagnoses of pervasive developmental disorders. The American Journal of Psychiatry, 169, 1056-1064.

Kanner, L. (1943). Autistic disturbances of affective contact (pp. 217-250). publisher not identified.

Lord, C., Petkova, E., Hus, V., Gan, W., Lu, F., Martin, D. M., ... & Risi, S. (2012). A multisite study of the clinical diagnosis of different autism spectrum disorders. Archives of general psychiatry, 69(3), 306-313.

Matson et al. (2012). DSM-IV vs DSM-5 diagnostic criteria for toddlers with autism. Developmental Neurorehabilitation, 15, 185-190.

Mattila et al. (2011). Autism spectrum disorders according to DSM-IV-TR and comparison with DSM-5 draft criteria: An epidemiological study. Journal of the American Academy of Child & Adolescent Psychiatry, 50, 583-592.

McPartland et al. (2012). Sensitivity and specificity of proposed DSM-5 diagnostic criteria for autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51, 368-383.

Rondeau, E., Klein, L. S., Masse, A., Bodeau, N., Cohen, D., & Guilé, J. M. (2011). Is pervasive developmental disorder not otherwise specified less stable than autistic disorder? A meta-analysis. Journal of Autism and Developmental Disorders, 41(9), 1267-1276.

Young, R. L., & Rodi, M. L. (2013). Redefining Autism Spectrum Disorder using DSM-5: The implications of the proposed DSM-5 criteria for Autism Spectrum Disorders. Journal of Autism and Developmental Disorders, 43.

Guthrie, W., Swineford, L. B., Wetherby, A. M., & Lord, C. (2013). Comparison of DSM-IV and DSM-5 factor structure for toddlers with Autism Spectrum Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 52, 797-805.



A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following: (cont’d) 3. Difficulties following rules for conversation and

storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction.

4. Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meanings of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation)



B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination

C. The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities)

D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by ASD, intellectual disability, global developmental delay, or another mental disorder.



D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by ASD, intellectual disability, global developmental delay, or another mental disorder.


Medical Diagnosis v. Educational Diagnosis

Fundamental distinction between a medical diagnosis and an educational determination is the impact the symptoms/diagnosis has on student learning

Medical evaluation = Diagnosis

Educational evaluation = Category of eligibility for services


Some Interesting Facts!

Autism is estimated to occur in 1:50 in US

There is no known cause and no known cure

“Refrigerator Moms” and poor parenting do not cause Autism

Boys are 5 times more likely than girls

Autism runs in families

Autism costs a family $100,000 a year on average


autism spectrum disorders in dsm-5ihspta.weebly.com/uploads/3/9/1/4/39140819/dsm-5...or verbal and...

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