Who Ordered This? DSM 5 and Autism Spectrum Disorders Jarrett Barnhill MD UNC School of Medicine Jarrett_Barnhill@med.unc.edu
Goals Review the scientific reasoning behind these changes Explore who is likely to left out very young children and a group of individuals with PDD.NOS Discuss the problems the NIMH had with the blend of categorical and dimensional i features of ASD.
Organizational structure Harmonization with ICD 11 Dimensional approach v. categorical issue of NOS use, state/trait, G E interactions, subsyndromal disorder; broader class int/ext. disorders, gender issues Developmental and lifespan considerations Multi axial system formulation, specifiers Neurodevelopmental disorders
DSM 5 Criteria: Social communication requires 3/3 criteria Restrictive/repetitive behaviors, cognitions 2/4 Symptoms appear during development Significant impairment across multiple settings (ecological and functional) Not better accounted for by ID(IDD), GDD delays, y, social communication (Pragmatics)
Social Communication deficits Merging of traits communication is a social behavior, ethological framework Social reciprocity timing and recognition Nonverbal communication perception, processing and spontaneous use of prosody, structure of language; pragmatics Developing, maintaining, understanding social relationships, context driven, play, ToM
Restrictive, Repetitive Patterns Severity independent of Social communication Stereotyped, repetitive movements interests, behaviors, nonfunctional use of objects Insistence on sameness, intensity of reactions Highly restrictive, fixated interests, overselectivity Sensory processing, preferences, integration
Severity Replace older AS, PDD.NOS Based on the level of adaptive skills/supports needed use of open ended phrase very substantial, substantial, supports Apply to both hsocial communication i and repetitive/restrictive Level of functional deficit, degree of interference, set shifting/perseveration
Specifiers Factors that influence change state changes Rate social communication and RRBC s separately With/without accompanying: ID(IDD); language impairment; i known medical, genetic, environmental conditions Neurodevelopmental, behavioral, mental Dx Catatonia
Differential Dx Rett s syndrome Selective mutism, severe anxiety Language disorder (social pragmatics disorder) ID(IDD) severe Stereotypic t movement disorder d SIB ADHD no longer excluded Schizophrenia erosion of boundaries, comorbidities (70%)
The Science of ASD Why questions Mergesocial and communication deficits? Eliminate PDD.NOS, Rett s, Asperger s and childhood disintegrative disorder? Change the multi axial model of DX? Remove ADHD and other conditions from the list of exclusion criteria? Use qualifiers IDD, symptomatic ASD
Concerns and Controversies Who will be disqualified? Very young children at risk modification of criteria 2/3 for A ; A; 1/4 for B developmental issues and early interventions PDD.NOS use of Dx, 38 47% will be excluded d Fit with ADOS, ADI, cut off points Not immutable, real change, NIMH controversy, lumping/splitting p gdebate
Conclusions Gradual transformation from a strictly categorical to a dimensional/etiology driven models research models Formulation retains importance Many will continue to use 3 axial ilmodel dlhbi habit, insurance coverage, Axis IV, V (?validity) Will change over time wide net v. narrow focus