Cengage Learning Webinar, Psychology: Autism Spectrum Disorders: Diagnostic Changes in DSM-5

Delivering Next Generation Care

Michael Troy, Ph.D., L.P.Children’s Hospitals and Clinics of

MN

March 12, 2013

Autism Spectrum Disorders: Diagnostic Changes in DSM-5


Autism Spectrum Disorders: Diagnostic Changes in DSM-5

“Whenever we have made a word… to denote a certain group of phenomena, we are prone to suppose a substantive entity beyond the phenomena.”

~ William James (1890) ~


A Rose By Any Other Name?

• Pervasive Developmental Disorders (PDD)

• Autistic Disorder• Asperger’s Disorder• PDD-NOS

• Autism• Autism Spectrum

Disorders (ASD)• High Functioning

Autism (HFA)• Atypical Autism


Descriptive & Diagnostic Nomenclature

• Are all these terms interchangeable?• Why did a shadow nomenclature develop?• Does the cut-off point for diagnosis reflect a

true junction or an arbitrary discontinuity (cleaving nature at the joint vs. cleaving meatloaf)?

• What are the consequences of invalid categorical labeling? Does it matter? Why?


Diagnostic Classification

For example: Asperger’s Disorder vs. High Functioning Autism•More of a debate than formal distinction•HFA implies that there is an autism continuum from mild to severe and that either:

– Asperger’s exists and HFA is different, or– Asperger’s and HFA are basically the same thing


Diagnostic Classification

• Medical vs. Mental Health• Categorical vs. Dimensional• Mental Health Diagnostic Classification:

A ‘Useful Fiction’• DSM-IV >> DSM-5: Process, Politics,

Research, and Practice• *Revision of DSM Autism Diagnosis: Battle of

the ‘Splitters’ vs. the ‘Lumpers’*Note: The Lumpers are winning


Relevant Developmental Tasks and Challenges

–Social cognition

–Theory of Mind

–Affective social competence


Pervasive Developmental Disorders (DSM-III-R,1987-93)

Autistic Disorder

Pervasive Developmental Disorder-NOS


Pervasive Developmental Disorders (DSM-IV)

Autistic Disorder

Asperger’s Disorder


C. Lord


Pervasive Developmental Disorders (DSM-IV)

Autistic Disorder


Childhood Disintegrative

Disorder

Rett’s Disorder


C. Lord


Autistic Disorder


Childhood Disintegrative

Disorder

Rett’s Disorder


Cognitive Delay with Behavior Disorders

Nonverbal LD

Fragile XSevere

Receptive/Expressive Language Disorder

C. Lord


Autism Spectrum Disorders

DSM-5 Diagnostic Criteria


DSM-5Autism Spectrum Disorders


Autism Spectrum Disorder in the DSM

• Currently in DSM-IV:– Pervasive Developmental Disorders

• Autism• Asperger Syndrome• Other specific disorders• PDD-NOS



DSM-5– New Name: Autism Spectrum Disorder– Includes DSM IV’s Autistic Disorder (autism),

Asperger’s Disorder, Childhood Disintegrative Disorder, & PDD-NOS (Rett’s is dropped)



• Rationale for DSM-5 Changes:– Differentiation of autism spectrum disorders

from typical development & other disorders done reliably and with validity;

– While within category distinctions inconsistent, variable, and often associated with severity, language level or intelligence rather than features of the disorder


DSM IV Diagnostic Criteria

Autistic Disorder


PDD-NOS

Social Interaction (2)

Communication (1)

Restricted & Repetitive Behavior 1)

N. Ashoomoff


Social/Communication Deficits (3)

Fixated Interests & Repetitive Behavior (2)

Autism Spectrum Disorders

DSM-5 Diagnostic Criteria


Diagnostic Criteria in DSM

• Currently in DSM-IV:– Qualitative impairment in social interaction (2)– Qualitative impairment in communication (1)– Restricted, repetitive behaviors (1)

• DSM-5:– Social/communication deficits (3)– Fixated interests and repetitive behaviors (2)


Diagnostic Criteria in DSM-5

A. Social/communication deficits (All 3)– Deficits in social-emotional reciprocity– Deficits in nonverbal communicative behaviors

used for social interaction– Deficits in developing and maintaining

relationships, appropriate to developmental level



B. Fixated interests and repetitive, restricted behaviors (at least 2)

– Stereotyped or repetitive speech, motor movements, or use of objects

– Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change

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

– Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment



C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)

D. Symptoms together limit and impair everyday functioning.


Diagnostic Criteria in DSM-5Severity Level for ASD

Social Communication Restricted interests & repetitive behaviors

Level 3 ‘Requiring very substantial support’

Severe deficits in verbal & nonverbal social communication causing severe impairments in functioning; very limited initiation of social interactions & minimal response to social overtures.

Preoccupations, fixated rituals and/or repetitive behaviors markedly interfere with functioning in all spheres. Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interest or returns to it quickly.

Level 2 ‘Requiring substantial support’

Marked deficits in verbal and nonverbal social communication; social impairments apparent even with supports; limited initiation of social interactions & reduced or abnormal response to social overtures from others.

RRBs and/or preoccupations or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress or frustration is apparent when RRB’s are interrupted; difficult to redirect from fixated interest.

Level 1 ‘Requiring support’

Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions & demonstrates atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions.

Rituals and repetitive behaviors (RRB’s) cause significant interference with functioning in one or more contexts. Resists attempts by others to interrupt RRB’s or to be redirected from fixated interest.



– Additionally, to ensure that etiology is indicated, where known, clinicians encouraged to utilize the specifier:

“Associated with Known Medical Disorder or Genetic Condition”

– In this way, it will be possible to indicate that a child with ASD has Fragile X syndrome, Tuberous Sclerosis, 22q deletion, etc.


Potential consequences?

• Possibly fewer individuals diagnosed with ASD (but why?)• Severe, classic autism clear to all; but at the milder end of

the spectrum, the boundaries are fuzzy.• It’s at this milder end of the boundary that rates may drop

(e.g., Asperger’s vs. Autism)• Interventions may then be targeted to more severely-

disabled individuals• Possible changes to:

– Access to educational and other services– Support services for individuals and families– Advocacy groups– Self understanding


Potential Response to Concerns

Allan Frances, MD (Duke U, DSM-IV) … How can we achieve a more precise diagnosis of autism AND not deprive services for those who need them?

– Decouple school services from the DSM diagnosis of autism.– Instead of DSM diagnosis, the child's specific learning and

behavioral problems should guide eligibility and individualized planning

– Children who now get inappropriately labeled autistic should lose the inaccurate diagnosis, but not lose the needed services.


Letter on DSM-5February 2, 2012

Autism Speaks is concerned that planned revisions to the definition of autism spectrum disorder (ASD) may restrict diagnoses in ways that may deny vital medical treatments and social services to some people on the autism spectrum. These revisions concern the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), scheduled for publication in spring 2013.

We have voiced our concerns and will continue to directly communicate with the DSM-5 committee to ensure that the proposed revision does not discriminate against anyone living with autism. While the committee has stated that its intent is to better capture all who meet current diagnostic criteria, we have concluded that the real-life impact of the revisions has, to date, been insufficiently evaluated. ……..


Summary

• Autism is a spectrum disorder• Ergo, Autism Spectrum Disorder• This means that symptoms can present in

wide variety of combinations and from mild to severe.

• New criteria meant to improve discriminant validity, while reflecting within category heterogeneity



• Are all these terms interchangeable? No• Why did a shadow nomenclature develop? A

veridicality gap…• Does the cut-off point for diagnosis reflect a

true junction or an arbitrary discontinuity (cleaving nature at the joint vs. cleaving meatloaf)? Meatloaf is meatloaf… but it’s not chicken



• What are the consequences of invalid categorical labeling? Does it matter? Why?– It’s hard to have our diagnostic decision making

more clear than diagnostic system.– Yes– See slides 1 – 28…


Autism Spectrum Disorder

Bonus Features


ASD: Consensus & Trends• Developmental Course

– Characteristic symptoms generally evident between 2 & 4– Almost always a lifelong disorder– Involving neurological, social communication & interactions,

and behavioral domains– Higher functioning end of spectrum may not be evident until

social demands are developmentally relevant• Autism recognized as a ‘spectrum disorder’

– Family patterns, severity variations• Prevalence 1 in 110 (CDC average) or 1% of the population

– Puzzle of “rising prevalence”; some arguing for higher prevalence rates

– Male: Female ration 4/5:1


ASD: Consensus & Trends• Recognized as early emerging disorder of brain development

– ASDs among most highly heritable of psychiatric disorders– Complex G x E processes suspected– Many theories about E factors– Hunt on for biomarkers and neurodevelopmental processes

• Physiological Hypotheses (examples)– Extreme male brain theory: focus on sex-linked dimensions of brain

functioning– Growth dysregulation hypothesis: suggests that atypical processes of

brain growth & organization lead to the primary symptoms of autism• Early diagnosis and intervention becoming gold standard

– Behavioral intervention has strong evidence of efficacy– The most successful interventions are those that are delivered early

and intensively across a variety of domains of functioning (social & language; home & school)



Autism Spectrum Disorder

‘Six Developmental Trajectories Characterize Children with Autism’

PEDIATRICS 129(5), May 2012

•Large, longitudinal study of autism developmental trajectories•Describes 6 specific trajectories, across 3 core symptom domains (Communication, Social, Repetitive Behaviors)•For example, ‘Bloomers’ vs. ‘High’ vs. ‘Low’•Reflects the significant heterogeneity of symptom patterns and outcomes•And, presumably, etiology


ASD Eye Tracking Findings


ASD Eye Tracking Findings


Courschesne et al• Is abnormal growth in brain

development the neural basis for autism?

• Evidence of age-specific anatomical abnormalities

• Early excess of neurons

• That must begin prenatally

• Later remodeling (pruning) gone awry as well

• Continued changes with age

Education

Cengage Learning Webinar, Psychology: Autism Spectrum Disorders: Diagnostic Changes in DSM-5