Survey of Autism Spectrum Disorder Concerns Presented by Curtis L. Timmons, Ph.D., LSSP 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 5. Understand other diagnoses which share traits with ASD 6. Review Case Studies 7. How to improve treatment team assessments 8. Completing the report 1 2 3 1
DSM-5 requires functional impairments in two broad domains of concerns as well as the majority of sub-domains. The predictive validity of most test instruments continue to reference membership to a group that no longer meets diagnostic criteria. Social anxiety Communication Disorders Sensory Processing difficulties * developmental delays * intellectual limitations * communication disorders, * limited social skills, * anxiety Intellectual limitations Autism Developmental Delays 4 5 6 2
Thus, the predictive validity to the group that meets the DSM-5 criteria may be quite low. If new tests continue to predict membership to the previous group A simple cutoff score can not account for the options one must consider before concluding the presence of ASD. False positives Incorrectly identified as autism FaFa Autism Spectrum Disorder False positives 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. 7 8 9 3
SEVERITY LEVELS OF ASD FUNCTIONAL INTERPETATION SEVERE: Requires Very Cannot function without one on one Substantial Support supervision and assistance throughout the day. MODERATE: Requires close proximity and redirection Requires Substantial throughout the day. Support Requires ongoing awareness and coaching MILD: of skills related to adjustment, behaviors Requires Support and relationships. Examples of Substantial Impact on Daily Functioning SASDC: Interaction and LIMITED DSM-5 DIAGNOSTIC Observation Form ratings COMMUNICATIONS AND SEVERITY SOCIAL INTERACTION Examples 5 CAN NOT FUNCTION Nonverbal SEVERE Does not talk/interact with others Requires very substantial support Substantial Intensely avoids and withdraws from all forms of interaction. 4 SIGNIFICANT DISTRESS WITHIN INTERACTIONS: Generally nonverbal, MODERATE Moderate to Commonly upset by requirements to Requires substantial support interact. Agitation, emotional meltdown substantial and withdrawal 3 NOTABLE AVOIDANCE OF INTERACTION: Prefers no interaction but can interact with MILD Moderate guidance and coaching. Requires support SUBCLINICAL CONCERNS DO NOT MEET CRITERIA FOR ASD DIAGNOSIS 2 PREFERENCE TO NOT INTERACT with others. Has social skills to Not Clinical Mild to moderate interact yet often prefers solitary activities. Can engage with other if interested. 1 LIMITED INTEREST IN OTHERS. Limited social skills, Is somewhat indifferent to Not Clinical Mild others or often engaged in solitary play. Social skills are, otherwise, adequate 0 GOOD COMMUNICATIONS AND SOCIAL SKILLS. Engages with others Joins activities Not Clinical Minimal at developmental level Examples of Substantial Impact on Daily Functioning SASDC: Interaction and DSM-5 INTEREST IN DINOSAURS Observation Form ratings DIAGNOSTIC IMPACT ON DAILY FUNCTIONING SEVERITY Examples 5 CAN NOT FUNCTION SEVERE Substantial Emotionally Dependent: Melt-down if Requires very he does not have his favorite dinosaur substantial support 4 OBSESSION: Knows the names of 12-20 Moderate to substantial dinosaurs, what they eat, their weight MODERATE and their scientific name. Can only talk Requires about dinosaurs. substantial support 3 STRONGLY PREFERRED ACTIVITY: Only Moderate wants to play with dinosaurs. MILD Difficulty transitioning to another Requires support activity. Theme of conversation generally involves dinosaurs. SUBCLINICAL CONCERNS; DOES NOT MEET CRITERIA FOR ASD DIAGNOSIS 2 Preferred Activity: Favorite toy, Mild to moderate watches TV shows on dinosaurs. Not Clinical Knows some basic information regarding dinosaurs. Not an obsession of interest. Has other interests as well. 1 Interest. Has several dinosaur toys. Mild Can shift from this interest to other Not Clinical interests. 0 Passive Interest: Occasionally plays Minimal with dinosaurs and watches shows Not Clinical regarding dinosaurs. 10 11 12 4
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 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 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 alone 4 Has difficulties in making friends 5 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 to interact) 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 13 14 15 5
ASD DOMAIN 2/Subdomain 1: Repetitive Motor movement/use of objects/speech 1 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 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 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) 6 Use of you when referring to self 16 17 18 6
ASD DOMAIN 2/Subdomain 4: Processing of Sensory Information 1 Over reacts to sensory input (lights/sounds/textures) 2 Under reaction to sensory input 3 Overly focused on sensory stimuli (touch, smell, visual) 4 Ritualistic behaviors involving tastes/smell/texture/food 5 Indifference to extreme temperature (heat or cold) 6 Overreaction to specific sounds 7 Overreaction to specific textures 8 Excessive smelling of objects 9 Excessive touching/feeling of objects 10 Visual fascination with lights 11 Visual fascination with movement/spinning objects 12 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 testsession 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. 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. 19 20 21 7
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. 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. 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. Social-Emotional Reciprocity Nonverbal Communications and Interaction Relationship Skills AVERAGE SCORE FOR COMMUNICATION DOMAIN 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 Teacher average 22 23 24 8
The SASDC provides layers of confidence in meeting DSM-5 requirements Domain Scores Subdomain Scores Item Analysis Interaction and Observation Form Diagnostic Criteria Checklist Composite Score Clinical Judgement and Alternative Diagnoses The DCC organizes our data: 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? Criteria C Criteria D Criteria E Let s get back to criteria C, D, and E. REQUIRES Based upon available history, were symptoms CAREFUL present in the early developmental period? CONSIDERATION AND Based upon all sources of information DELIBERATION available, do symptoms cause clinically substantial impairment in social, occupational or other important areas of functioning? 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 YES NO ASD Criteria Met YES NO ASD Criteria Met YES NO 25 26 27 9
Criteria E is the greatest challenge in offering an ASD diagnosis. 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? SELECTIVE MUTISM MAJOR DEPRESSION GLOBAL DEVELOPMENTAL DELAYS AUTISM Mental health concerns that share traits with ASD. Anxiety ADHD Bipolar Disorder Communication Disorders Depression Oppositional Defiant Disorder Reactive Attachment Disorder Disruptive Mood Dysregulation Disorder Personality Disorders Social (Pragmatic) Communication Disorder Global Developmental Delay Post-traumatic Stress Disorder neurological problems Intellectual Disability Psychotic Disorders Selective Mutism 28 29 30 10
Other concerns that must be considered Without considering other related concerns The DSM-5 states the following: Medical Mental Age Intellectual Age History of problems (seizures) Birth trauma Head injuries History of abuse Mother s use of alcohol and drug during pregnancy Stability of the Previous social Family s mental home opportunities health history we are right back where we started misdiagnosis. Sensory DEVELOPMENTAL Mental DELAYS age ASD SPCD ANXIETY RAD 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. 31 32 33 11
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. 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. 34 35 36 12
THANK YOU. FOR MORE INFORMATION On the internet: SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS (SASDC) Autismtest-dsm5.com 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 THANK YOU. Contact information Curtis L. Timmons, Ph.D., LSSP 254-751-9606 email: drctimmons@aol.com Curtis Timmons, Ph.D. 6801 Sanger, #104 Waco, Texas 76710 Go 37 38 39 13