Autism Spectrum Disorders in DSM-5

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1 Autism Spectrum Disorders in DSM-5 JILL 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 I U H EA LT H. O R G September 18, 2015

2 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

3 Where it All Began Sort Of? Nervous Child 2: , 1943

4 Where It All Began Sort Of? 1944

5 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)

6 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

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

8 What is DSM-IV-TR? Rett s Syndrome/CDD Rett s Syndrome Childhood Disintegrative Disorder 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 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

9 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

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16 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

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18 Changes 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)

19 Changes DSM-IV TR DSM-5 Pervasive Developmental Disorder No indication about sensory differences Autism Spectrum Disorder Added hyper- or hypo-reactivity to sensory input (to RRB) Language delay criteria Delay in language removed Must be present before age 3 years 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

20 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.

21 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). Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved.

22 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. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved.

23 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. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved.

24 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.

25 Diagnostic Specifiers DSM 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

26 Specifier: Level of Support Required Severity Level Level 1: Requiring Support Social Communication 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 Restricted, Repetitive Behaviors Inflexibility of behavior causes significant interference with functioning in one or more contexts Difficulty switching between activities Problems of organization and planning hamper independence

27 Specifier: Level of Support Required Severity Level Level 2: Requiring substantial support Social Communication 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 Restricted, Repetitive Behaviors 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.

28 Specifier: Level of Support Required Severity Level Level 3: Requiring very substantial support Social Communication 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. Restricted, Repetitive Behaviors 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.

29 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

30 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

31 Sample Diagnosis (DSM-5) 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)

32 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

33 Intellectual Disability Replaces the term mental retardation Mental Retardation (DSM-IV-TR) Mild (IQ/Adaptive = to 70) Moderate (IQ/Adaptive = to 50-55) Severe (IQ/Adaptive = 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

34 Intellectual Disability 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

35 DSM-5Backlash!

36 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

37 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

38 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)

39 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

40 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

41 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

42 Questions??

43 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), Asperger, H. (1944). Die Autistischen Psychopathen im Kindesalter. European Archives of Psychiatry and Clinical Neuroscience, 117(1), 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, Kanner, L. (1943). Autistic disturbances of affective contact (pp ). 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), Matson et al. (2012). DSM-IV vs DSM-5 diagnostic criteria for toddlers with autism. Developmental Neurorehabilitation, 15, 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, 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, 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), 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,

44 Social (Pragmatic) Communication Disorder 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)

45 Social (Pragmatic) Communication Disorder 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.

46 Social (Pragmatic) Communication 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.

47 Intellectual Disability

48 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

49 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

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