goals of the workshop survey of autism …...between the dsm-iv and the dsm-5 2. understand the...

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SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS

Survey of Autism Spectrum Disorder Concerns

Presented by

Curtis L. Timmons, Ph.D., LSSP

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GOALS OF THE WORKSHOP

1. Understand why there were changes between the DSM-IV and the DSM-5

2. Understand the current criteria for

ASD

3. Video training to score ASD criteria

4. Developing an instrument to harvest diagnostic information

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5. Understand other diagnoses which share traits with ASD

6. Review Case Studies

7. How to improve treatment team assessments

8. Completing the report

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* developmental delays

* intellectual limitations

* communication disorders,

* limited social skills,

* anxiety

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DSM-5 requires functional impairments in two broad domains of concerns as well as

the majority of sub-domains.

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The predictive validity of most test instruments continue to reference membership to a group

that no longer meets diagnostic criteria.

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Social anxietyCommunication

Disorders

Sensory Processing difficulties

Intellectual limitations Developmental

DelaysAutism

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Thus, the predictive validity to the group that

meets the DSM-5 criteria may be quite low.

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FaFa Autism Spectrum Disorder

False positives

Incorrectly identified as

autism

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If new tests continue to

predict membership to

the previous group

ASDFalse positives

A simple cutoff score can not account for the options one must consider before concluding

the presence of ASD.

▪ All three Domain 1 criteria must be met.

▪ Two of the four Domain 2 criteria must be met.

▪ Symptoms are not better attributed to another mental health concern.

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SEVERITY LEVELS OF ASD

FUNCTIONAL INTERPETATION

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SEVERE:Requires Very

Substantial Support

Cannot function without one on one

supervision and assistance throughout

the day.

MODERATE:Requires Substantial

Support

Requires close proximity and redirection

throughout the day.

MILD:Requires Support

Requires ongoing awareness and coaching

of skills related to adjustment, behaviors

and relationships.

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Examples of Substantial Impact on Daily FunctioningSASDC: Interaction and

Observation Form ratingsLIMITED

COMMUNICATIONS AND

SOCIAL INTERACTION

DSM-5 DIAGNOSTIC

SEVERITY

Examples

5

Substantial

CAN NOT FUNCTION Nonverbal

Does not talk/interact with others

Intensely avoids and withdraws from all forms of interaction.

SEVERERequires very substantial support

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Moderate to

substantial

SIGNIFICANT DISTRESS WITHIN

INTERACTIONS: Generally nonverbal,

Commonly upset by requirements to interact. Agitation, emotional meltdown

and withdrawal

MODERATERequires substantial support

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Moderate

NOTABLE AVOIDANCE OF INTERACTION:

Prefers no interaction but can interact with

guidance and coaching.MILD

Requires support

SUBCLINICAL CONCERNS DO NOT MEET CRITERIA FOR ASD DIAGNOSIS2

Mild to moderate

PREFERENCE TO NOT INTERACT

with others. Has social skills to

interact yet often prefers solitary

activities. Can engage with other if

interested.

Not Clinical

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Mild

LIMITED INTEREST IN OTHERS. Limited

social skills, Is somewhat indifferent to

others or often engaged in solitary play. Social skills are, otherwise, adequate

Not Clinical

0

Minimal

GOOD COMMUNICATIONS AND SOCIAL

SKILLS. Engages with others Joins activities

at developmental level Not Clinical

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Examples of Substantial Impact on Daily Functioning

SASDC: Interaction and Observation Form ratings

IMPACT ON DAILY FUNCTIONING

INTEREST IN DINOSAURS DSM-5

DIAGNOSTIC SEVERITY

Examples

5 Substantial

CAN NOT FUNCTION Emotionally Dependent: Melt-down if he does not have his favorite dinosaur

SEVERE Requires very substantial support

4 Moderate to substantial

OBSESSION: Knows the names of 12-20 dinosaurs, what they eat, their weight and their scientific name. Can only talk about dinosaurs.

MODERATE

Requires substantial support

3 Moderate

STRONGLY PREFERRED ACTIVITY: Only wants to play with dinosaurs. Difficulty transitioning to another activity. Theme of conversation generally involves dinosaurs.

MILD

Requires support

SUBCLINICAL CONCERNS; DOES NOT MEET CRITERIA FOR ASD DIAGNOSIS

2 Mild to moderate

Preferred Activity: Favorite toy, watches TV shows on dinosaurs. Knows some basic information regarding dinosaurs. Not an obsession of interest. Has other interests as well.

Not Clinical

1 Mild

Interest. Has several dinosaur toys. Can shift from this interest to other interests.

Not Clinical

0 Minimal

Passive Interest: Occasionally plays with dinosaurs and watches shows regarding dinosaurs.

Not Clinical

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ASD DOMAIN 1: Subdomain 1:Social-Emotional Reciprocity

1 Limited communications and social interaction 2 Does not have normal back-and-forth conversation

3 Does not share interests, thoughts, or emotions

4 Does not initiate social interactions

5 Does not respond to social interactions (return wave or smile)

6 Does not attempt to engage with others

7 Does not imitate others

8 Language is used to label/request rather than share feelings/converse

9 Does not perceive or understand social cues

10 Absence of speech

11 Repeats what others say in a mechanical fashion (echolalia)

12 Uses of words/phases do not fit the social situation

13 Awkward, mechanical or inappropriate manner of greeting and interacting

14 Language is developmentally delayed

15 Limited understanding of speech

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ASD DOMAIN 1: Subdomain 2:Nonverbal Communicative Behaviors

Used for Interaction

1 Does not make eye contact with others

2 Does not use gestures when communicating

3 Does not use facial expressions when communicating

4 Speech intonation is flat or mechanical in nature

5 Does not share interests with others

6 Does not understand others’ gestures

7 Body language is odd or unusual

8 Does not use nonverbal communications (pointing, sharing)

9 Poorly integrated eye contact, gestures & facial expressions

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ASD DOMAIN 1/Subdomain 3:Maintaining and Understanding Relationships

1 Does not understand how to maintain relationships

2 Does not understand how to interact with others

3 Does not use imagination in playing alone4 Has difficulties in making friends5 No interest in peers

6 Does not know how to join conversations

7 Conversation is one sided and only talks about special interest

8 Does not show awareness/interests in others

9 Rejection of others (hugs, attempts tointeract)

10 Passive or disconnected in relations

11 Aggressive or disruptive attempts to interact

12 No social play

13 Does not use imagination during play with others

14 Play follows precise rules or is otherwise very controlling

15 Does not understand what behavior is appropriate in a situation

16 Prefers to play alone

17 Prefers to interact with only younger or older people

18 Desires to play but does not understand how to do so

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ASD DOMAIN 2/Subdomain 1: Repetitive Motor movement/use of

objects/speech1 Unusual motor movements such as hand flapping, finger flicking,

rocking, twirling, spinning)

2 Unusual use of objects (lines up toys, spins/flips objects)

3 Unusual repetition of words/phrases

4 Frequent use of meaningless words or phrases

5 Frequently used words/phrases do not fit context of interaction

6 Use of “you” when referring to self

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ASD DOMAIN 2/Subdomain 2:Routines and Rituals

1 Insistence on sameness/routines

2 Cannot tolerate changes in routine

3 Extreme distress with small changes in routine

4 Exact repetition of verbal or nonverbal behavior

5 Difficulty with transition from one activity to another

6 Rigid thinking patterns (cannot tolerate differences)

7 Rigid rules of play or interaction

8 Tasks must be performed in a precise manner

9 Need to eat the same food every day

10 Need to take the same route every day

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ASD DOMAIN 2/Subdomain 3:Interests

1 Has a preoccupation with one or two specific interests

(dinosaurs, weather)

2 Strong attachment to a given object/toy

3 Preoccupation with a given object/toy

4 Perseveration of interests (does not change interests)

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ASD DOMAIN 2/Subdomain 4: Processing of Sensory Information

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1 Over reacts to sensory input (lights/sounds/textures)2 Under reaction to sensory input3 Overly focused on sensory stimuli (touch, smell, visual)4 Ritualistic behaviors involving tastes/smell/texture/food5 Indifference to extreme temperature (heat or cold)6 Overreaction to specific sounds7 Overreaction to specific textures 8 Excessive smelling of objects9 Excessive touching/feeling of objects

10 Visual fascination with lights 11 Visual fascination with movement/spinning objects12 Excessive food restrictions (eats only specific foods)13 Indifference to pain

Goals of developing an assessment instrument

• We also need to represent daily functioning rather than test-session adjustment.

• We need to represent information from two or more settings.

• We need to integrate clinical judgement into information from raters.

• We need to involve raters who are most familiar with the individual.

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The items for the SASDC are taken directly from the DSM-5

DSM-5

As the DSM-5 lists

a trait related to

ASD, the trait is converted to a SASDC item to be rated.

SASDC

Every item on the SASDC is presented

by the DSM-5™ as a diagnostic trait for

ASD.

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Concerns in developing the protocol

The protocol needs to be developed in such a manner that independent raters document concerns in two (or more) different settings.

(family ratings and teacher ratings)

We need account for similarities and differences in the ratings.

At times the rating may represent rater bias.

At times the ratings may represent different adjustment in different settings.

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Concerns in developing the protocol

Results of the ratings must be clearly presented to explain the various domains and subdomains.

The test scores can not be used as the sole determiner of a diagnosis of ASD. A cut-off score is not sufficient.

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Domain one has three subdomains. We can illustrate 1. the rating for each rater for each subdomain, present the average for each

subdomain, and show the average for each rater.P 83

T 85

O 0

A 84

P 73

T 67

O 0

A 70

P 82

T 63

O 0

A 73

P 79

T 72

O 0

A 76

Social-Emotional Reciprocity

Nonverbal Communications

and Interaction

Relationship Skills

AVERAGE SCORE FOR

COMMUNICATION

DOMAIN

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Teacher average

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The SASDC provides layers of confidence in meeting DSM-5 requirements

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Clinical Judgement and Alternative Diagnoses

Diagnostic Criteria Checklist

Interaction and Observation Form

Item Analysis

Subdomain Scores

Domain Scores

Composite Score

The DCC organizes our data:

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• Is there a prevalence of ASD traits?• Are there specific traits that are

consistently present?• Do traits cause substantial impact on

daily functioning?• Are the domain and subdomain

requirements met for an ASD diagnosis?

Let’s get back tocriteria C, D, and E.

Criteria C Based upon available history, were symptoms present in the early

developmental period?

Criteria D Based upon all sources of information available, do symptoms cause

clinically substantial impairment in social, occupational or other

important areas of functioning?

Criteria E Based upon expertise in rendering various psychological diagnoses, the

disturbance is not better explained by other mental health concerns,

intellectual disability or global developmental delay.

ASD Criteria Met

ASD Criteria Met

ASD Criteria Met

YESNO

YESNO

YESNO

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REQUIRES CAREFUL

CONSIDERATION AND

DELIBERATION

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Criteria E is the greatest challenge in offering an ASD diagnosis.

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According to the DSM-5…

you can not render an ASD diagnosis unless you have expertise in

rendering alternative diagnoses.

DIFFERENTIAL DIAGNOSES

To which diagnosis would you assign limited communications and social interaction?

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SELECTIVE MUTISM

√

MAJOR DEPRESSION

√

GLOBAL DEVELOPMENTAL

DELAYS

√

AUTISM

√

Mental health concerns that share traits with ASD.

Anxiety ADHD Bipolar Disorder Communication Disorders

Depression Disruptive Mood Dysregulation

Disorder

Global Developmental

Delay

Intellectual Disability

Oppositional Defiant Disorder

Personality Disorders

Post-traumatic Stress Disorder

Psychotic Disorders

Reactive Attachment

Disorder

Social (Pragmatic)

Communication Disorder

neurological problems Selective Mutism

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Other concerns that must be considered…

Medical problems

Mental Age Intellectual Age History of (seizures)

Birth trauma Head injuries History of abuse Mother’s use of alcohol and drug during pregnancy

Stability of the home

Previous social opportunities

Family’s mental health history

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Without considering other related concerns…

we are right back where we started…

misdiagnosis.

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ASD

DEVELOPMENTAL DELAYS

ANXIETY

RAD

SPCD

Sensory

Mental age

The DSM-5 states the following:

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.

The “well established” diagnosis suggests that this option is available

for only older teens/adults.

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PRESENTING A FORMAL DIAGNOSIS

When you offer the diagnosis of ASD, provide a severity

rating for each of the two domains.

DSM-5 diagnosis: 299.00 Autism Spectrum Disorder

Social Communication and Social Interaction (moderate)

Restrictive and Repetitive Behaviors (moderate to severe)

Also use specifiers as follows:

With or without accompanying intellectual impairment

With or without accompanying language impairment

Associated with a known medical or genetic condition or environment factor

Associated with another neurodevelopmental, mental or behavioral disorder

With catatonia

A WORD ABOUT ASSESSSMENT TEAMS

The DSM-5 expert is responsible for seeing that

the DSM-5 criteria are met.

To include a review of

• previous diagnoses

• alternative diagnoses

• medications

• history of seizures

• history of head injuries

• Other neurodevelopmental

concerns.

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A WORD ABOUT ASSESSSMENT TEAMS

The diagnosis is not a group vote.

Other team members play a supportive role

according to their area of expertise.

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THANK YOU….

FOR MORE INFORMATION

On the internet:

SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS (SASDC)

Autismtest-dsm5.com

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THANK YOU….

Workshops are available on:

• DSM-5 diagnoses

• Mental health concerns of children and teens

• Autism

• Building an ASD assessment team

• Survey of Autism Spectrum Disorder Concerns

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THANK YOU….

• Contact information

• Curtis L. Timmons, Ph.D., LSSP

• 254-751-9606

• email: [email protected]

Curtis Timmons, Ph.D.

6801 Sanger, #104

Waco, Texas 76710

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mailto:[email protected]

goals of the workshop survey of autism …...between the dsm-iv and the dsm-5 2. understand the...

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