Autism Spectrum Disorders:Diagnostic Changes in DSM-5    Michael Troy, Ph.D., L.P.  Children’s Hospitals and Clinics of   ...
Autism Spectrum Disorders:  Diagnostic Changes in DSM-5“Whenever we have made a word… todenote a certain group of phenomen...
A Rose By Any Other Name?• Pervasive Developmental • Autism  Disorders (PDD)         • Autism Spectrum• Autistic Disorder ...
Descriptive & Diagnostic Nomenclature• Are all these terms interchangeable?• Why did a shadow nomenclature develop?• Does ...
Diagnostic ClassificationFor example:Asperger’s Disorder vs. High Functioning Autism•More of a debate than formal distinct...
Diagnostic Classification• Medical vs. Mental Health• Categorical vs. Dimensional• Mental Health Diagnostic Classification...
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 Disorders (DSM-IV)              Autistic              Disorder             Asperger’s             ...
Pervasive Developmental Disorders (DSM-IV)                    Autistic    Childhood                    Disorder           ...
Severe                             Fragile X                                               Receptive/ExpressiveCognitive D...
DSM-5 Diagnostic Criteria     Autism Spectrum        Disorders             Delivering Next Generation                     ...
DSM-5Autism Spectrum Disorders             Delivering Next Generation                        Care
Autism Spectrum Disorder in the DSM• Currently in DSM-IV:  – Pervasive Developmental Disorders     • Autism     • Asperger...
Autism Spectrum Disorder in the DSMDSM-5 – New Name: Autism Spectrum Disorder – Includes DSM IV’s Autistic Disorder (autis...
Autism Spectrum Disorder in the DSM• Rationale for DSM-5 Changes:  – Differentiation of autism spectrum disorders    from ...
DSM IV Diagnostic Criteria         Autistic         Disorder                  Asperger’s  PDD-NOS                   Disord...
DSM-5 Diagnostic Criteria      Autism Spectrum         Disorders   Social/Communication Deficits (3)Fixated Interests & Re...
Diagnostic Criteria in DSM• Currently in DSM-IV:  – Qualitative impairment in social interaction (2)  – Qualitative impair...
Diagnostic Criteria in DSM-5A. Social/communication deficits (All 3)  – Deficits in social-emotional reciprocity  – Defici...
Diagnostic Criteria in DSM-5B. Fixated interests and repetitive, restricted   behaviors (at least 2)–   Stereotyped or rep...
Diagnostic Criteria in DSM-5C. Symptoms must be present in early   childhood (but may not become fully   manifest until so...
Diagnostic Criteria in DSM-5Severity Level                       Social Communication                        Restricted in...
Diagnostic Criteria in DSM-5– Additionally, to ensure that etiology is indicated,  where known, clinicians encouraged to u...
Potential consequences?• Possibly fewer individuals diagnosed with ASD (but why?)• Severe, classic autism clear to all; bu...
Potential Response to ConcernsAllan Frances, MD (Duke U, DSM-IV) … How can we achievea more precise diagnosis of autism AN...
Letter on DSM-5                             February 2, 2012Autism Speaks is concerned that planned revisions to the defin...
Summary• Autism is a spectrum disorder• Ergo, Autism Spectrum Disorder• This means that symptoms can present in  wide vari...
Descriptive & Diagnostic Nomenclature• Are all these terms interchangeable? No• Why did a shadow nomenclature develop? A  ...
Descriptive & Diagnostic Nomenclature• What are the consequences of invalid  categorical labeling? Does it matter? Why?  –...
Autism Spectrum Disorder   Bonus Features            Delivering Next Generation                       Care
ASD: Consensus & Trends• Developmental Course   – Characteristic symptoms generally evident between 2 & 4   – Almost alway...
ASD: Consensus & Trends• Recognized as early emerging disorder of brain development   –   ASDs among most highly heritable...
Delivering Next Generation           Care
Autism Spectrum Disorder  ‘Six Developmental Trajectories Characterize   Children with Autism’                            ...
ASD Eye Tracking Findings             Delivering Next Generation                        Care
ASD Eye Tracking Findings             Delivering Next Generation                        Care
Courschesne et al• Is abnormal growth in brain  development the neural  basis for autism?• Evidence of age-specific  anato...
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Cengage Learning Webinar, Psychology: Autism Spectrum Disorders: Diagnostic Changes in DSM-5

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This presentation reviews past and current diagnostic classification approaches to autism (and pervasive developmental disorders) discussed in the March 12, 2013 webinar. Michael Troy, Ph.D. discussed the changes planned for inclusion in the DSM-5 when it is published in May 2013. Changes in nomenclature (Autism Spectrum Disorder) and diagnostic criteria are highlighted.

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  • Three diagnostic domains become two Deficits in communication and social behaviors are inseparable and more accurately considered as a single set of symptoms with contextual and environmental specificities Delays in language are not unique nor universal in ASD and are more accurately considered as a factor that influences the clinical symptoms of ASD, rather than defining the ASD diagnosis Requiring both criteria to be completely fulfilled i mproves specificity of diagnosis without impairing sensitivity Providing examples for subdomains for a range of chronological ages and language levels increases sensitivity across severity levels from mild to more severe, while maintaining specificity with just two domains
  • Klin, A., Jones, W., Schultz, R., Volkmar, F., & Cohen, D. (2002). Archives of Gen Psychiatry, 59,809-816. Ristic et al., 2005
  • Klin, A. (2002). Asperger syndrome: Clinical features, assessment, and intervention. Clinical presentation to MN Association of Child Psychologists, Minneapolis, MN.
  • 2001 Courchesne, E., Karns, C., Davis, H.R., Ziccardi, R., Tigue, Z., Pierce, K., Moses, P., Chisum, H.J., Lord, C., Lincoln, A.J., Pizzo, S., Schreibman, L., Haas, R.H., Akshoomoff, N., Courchesne, R.Y. Unusual brain growth patterns in early life in patients with autistic disorder: An MRI study . Neurology, 57:245-254, 2001. 2011 Courchesne E, Mouton PR, Calhoun ME, Semendeferi K, Ahrens-Barbeau C, Hallet MJ, Barnes CC, Pierce K. Neuron number and size in prefrontal cortex of children with autism . JAMA. 2011 Nov 9;306(18):2001-10. PubMed PMID: 22068992 - Courchesne, E., Campbell, K., Solso, S. Brain growth across the life span in autism: Age-specific changes in anatomical pathology . Brain Research, 1380:138-45, 2011
  • Cengage Learning Webinar, Psychology: Autism Spectrum Disorders: Diagnostic Changes in DSM-5

    1. 1. Autism Spectrum Disorders:Diagnostic Changes in DSM-5 Michael Troy, Ph.D., L.P. Children’s Hospitals and Clinics of MN March 12, 2013 Delivering Next Generation Care
    2. 2. Autism Spectrum Disorders: Diagnostic Changes in DSM-5“Whenever we have made a word… todenote a certain group of phenomena,we are prone to suppose a substantiveentity beyond the phenomena.” ~ William James (1890) ~ Delivering Next Generation Care
    3. 3. A Rose By Any Other Name?• Pervasive Developmental • Autism Disorders (PDD) • Autism Spectrum• Autistic Disorder Disorders (ASD)• Asperger’s Disorder • High Functioning• PDD-NOS Autism (HFA) • Atypical Autism Delivering Next Generation Care
    4. 4. 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? Delivering Next Generation Care
    5. 5. Diagnostic ClassificationFor example:Asperger’s Disorder vs. High Functioning Autism•More of a debate than formal distinction•HFA implies that there is an autism continuumfrom mild to severe and that either: – Asperger’s exists and HFA is different, or – Asperger’s and HFA are basically the same thing Delivering Next Generation Care
    6. 6. 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 Delivering Next Generation Care
    7. 7. Relevant Developmental Tasks and Challenges – Social cognition – Theory of Mind – Affective social competence Delivering Next Generation Care
    8. 8. Pervasive Developmental Disorders (DSM-III-R,1987-93) Autistic Disorder Pervasive Developmental Disorder-NOS Delivering Next Generation Care
    9. 9. Pervasive Developmental Disorders (DSM-IV) Autistic Disorder Asperger’s Disorder Pervasive Developmental Disorder-NOS Delivering Next Generation Care C. Lord
    10. 10. Pervasive Developmental Disorders (DSM-IV) Autistic Childhood Disorder Rett’s Disintegrative Disorder Disorder Asperger’s Disorder Pervasive Developmental Disorder-NOS Delivering Next Generation Care C. Lord
    11. 11. Severe Fragile X Receptive/ExpressiveCognitive Delay with Language DisorderBehavior Disorders Autistic Nonverbal LD Disorder Childhood Disintegrative Rett’s Disorder Disorder Asperger’s Disorder Pervasive Developmental Disorder-NOS Delivering Next Generation C. Lord Care
    12. 12. DSM-5 Diagnostic Criteria Autism Spectrum Disorders Delivering Next Generation Care
    13. 13. DSM-5Autism Spectrum Disorders Delivering Next Generation Care
    14. 14. Autism Spectrum Disorder in the DSM• Currently in DSM-IV: – Pervasive Developmental Disorders • Autism • Asperger Syndrome • Other specific disorders • PDD-NOS Delivering Next Generation Care
    15. 15. Autism Spectrum Disorder in the DSMDSM-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) Delivering Next Generation Care
    16. 16. Autism Spectrum Disorder in the DSM• 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 Delivering Next Generation Care
    17. 17. DSM IV Diagnostic Criteria Autistic Disorder Asperger’s PDD-NOS Disorder Social Interaction (2) Communication (1)Restricted & Repetitive Behavior 1) Delivering Next Generation Care N. Ashoomoff
    18. 18. DSM-5 Diagnostic Criteria Autism Spectrum Disorders Social/Communication Deficits (3)Fixated Interests & Repetitive Behavior (2) Delivering Next Generation Care
    19. 19. 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) Delivering Next Generation Care
    20. 20. Diagnostic Criteria in DSM-5A. 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 Delivering Next Generation Care
    21. 21. Diagnostic Criteria in DSM-5B. 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 Delivering Next Generation Care
    22. 22. Diagnostic Criteria in DSM-5C. 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. Delivering Next Generation Care
    23. 23. Diagnostic Criteria in DSM-5Severity Level Social Communication Restricted interests & repetitive behaviorsfor ASD Severe deficits in verbal & nonverbal Preoccupations, fixated rituals and/or repetitiveLevel 3 social communication causing severe behaviors markedly interfere with functioning in all‘Requiring very impairments in functioning; very limited spheres. Marked distress when rituals or routines aresubstantial support’ initiation of social interactions & interrupted; very difficult to redirect from fixated interest minimal response to social overtures. or returns to it quickly. Marked deficits in verbal and nonverbal RRBs and/or preoccupations or fixated interests social communication; social appear frequently enough to be obvious to the casualLevel 2 impairments apparent even with observer and interfere with functioning in a variety of‘Requiring supports; limited initiation of social contexts. Distress or frustration is apparent whensubstantial support’ interactions & reduced or abnormal RRB’s are interrupted; difficult to redirect from fixated response to social overtures from interest. others. Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social Rituals and repetitive behaviors (RRB’s) causeLevel 1 interactions & demonstrates atypical or significant interference with functioning in one or more‘Requiring support’ unsuccessful responses to social contexts. Resists attempts by others to interrupt RRB’s overtures of others. May appear to or to be redirected from fixated interest. have decreased interest in social interactions. Delivering Next Generation Care
    24. 24. Diagnostic Criteria in DSM-5– 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. Delivering Next Generation Care
    25. 25. 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 Delivering Next Generation Care
    26. 26. Potential Response to ConcernsAllan Frances, MD (Duke U, DSM-IV) … How can we achievea more precise diagnosis of autism AND not depriveservices for those who need them? – Decouple school services from the DSM diagnosis of autism. – Instead of DSM diagnosis, the childs 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. Delivering Next Generation Care
    27. 27. Letter on DSM-5 February 2, 2012Autism Speaks is concerned that planned revisions to the definition ofautism spectrum disorder (ASD) may restrict diagnoses in ways thatmay deny vital medical treatments and social services to some people onthe autism spectrum. These revisions concern the 5th edition of theDiagnostic and Statistical Manual of Mental Disorders (DSM-5),scheduled for publication in spring 2013.We have voiced our concerns and will continue to directly communicatewith the DSM-5 committee to ensure that the proposed revision does notdiscriminate against anyone living with autism. While the committeehas stated that its intent is to better capture all who meet currentdiagnostic criteria, we have concluded that the real-life impact of therevisions has, to date, been insufficiently evaluated. …….. Delivering Next Generation Care
    28. 28. 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 Delivering Next Generation Care
    29. 29. Descriptive & Diagnostic Nomenclature• 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 Delivering Next Generation Care
    30. 30. Descriptive & Diagnostic Nomenclature• 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… Delivering Next Generation Care
    31. 31. Autism Spectrum Disorder Bonus Features Delivering Next Generation Care
    32. 32. 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 Delivering Next Generation Care
    33. 33. 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 Delivering Next Generation (social & language; home & school) Care
    34. 34. Delivering Next Generation Care
    35. 35. 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 symptomdomains (Communication, Social, Repetitive Behaviors)•For example, ‘Bloomers’ vs. ‘High’ vs. ‘Low’•Reflects the significant heterogeneity of symptom patterns andoutcomes•And, presumably, etiology Delivering Next Generation Care
    36. 36. ASD Eye Tracking Findings Delivering Next Generation Care
    37. 37. ASD Eye Tracking Findings Delivering Next Generation Care
    38. 38. 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 Delivering Next Generation Care
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