Autism spectrum disorders as per the DSM V guidelines, and its management

1. Autistic Spectrum Disorder
Presented by: Anish Dhakal
28th June, 2019

2. Contents
• Introduction and types
• Criteria
• Clinical feature and severity
• Screening and assessment
• Management

3. Introduction
• group of biologically based neurodevelopmental disorders
characterized by impairments in two major domains:
1) deficits in social communication and social interaction and
2) restricted repetitive patterns of behavior, interests, and activities
• ASD encompasses disorders previously known as:
• Autistic disorder (classic autism or Kanner's autism)
• Asperger syndrome
• childhood disintegrative disorder (CDD)
• Pervasive developmental disorder-not otherwise specified (PDD-NOS)

4. • DSM-5, a single diagnosis, "autism spectrum disorder"
has replaced previous subtypes (eg, Asperger syndrome,
"pervasive developmental disorder-not otherwise
specified") and the clinical heterogeneity is indicated with
specifiers for severity and associated conditions
• ICD-10 classifies ASD as "pervasive developmental
disorders
note: in ICD-10 symptoms must onset before age3 years but DSM-5, No age cut-off

7. 7
DSM-5 Criteria for
Autism Spectrum Disorder
A.Social Communication and Interaction (Must
have 3 of 3)
1.Deficits in social-emotional reciprocity
2.Deficits in nonverbal communicative behaviors
used for social interaction
3.Deficits in developing, maintaining, and
understanding social relationships
American Psychiatric Association (2013)

8. DSM-5 Criteria for
Autism Spectrum Disorder
B. Restricted, repetitive patterns of behavior, interests,
and activities (Must have 2 of 4)
1. Stereotyped or repetitive motor movements, use of objects, or speech
2. Insistence on sameness, inflexible adherence to routines, or ritualized
patterns of verbal or nonverbal behavior
3. Highly restricted, fixated interests that are abnormal in intensity or
focus
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory
aspects of the environment
8

9. Social Communication Criteria
(must have 3/3)
1. Deficits in social-emotional reciprocity:
• abnormal social approach and failure of normal
back-and-forth conversation
• reduced sharing of interests, emotions, or affect
• failure to initiate or respond to social interactions

10. Social Communication Criteria
(must have 3/3)
2. Deficits in nonverbal communicative behaviors used
for social interaction:
• Poorly regulated integrated verbal and nonverbal communication
• abnormalities in eye contact and body language or deficits in
understanding and use of gestures
• Total lack of facial expressions and nonverbal communication

11. Social Communication Criteria
(must have 3/3)
3. Deficits in developing, maintaining, and understanding social
relationships, ranging 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

12. Restricted/Repetitive Behavior Criteria
(must have 2/4)
1. Stereotyped or repetitive motor movements, use of objects, or speech, such as
• Simple motor stereotypes
• Lining up toys
• Flipping objects
• Echolalia
• Idiosyncratic phrases

13. Restricted/Repetitive Behavior Criteria
(must have 2/4)
2. Insistence on sameness, inflexible adherence to routines, or
ritualized patterns of verbal or nonverbal behavior, such as
• Extreme distress at small changes
• Difficulties with transitions
• Rigid thinking patterns
• Greeting rituals
• Need to take same route or eat same food every day

14. Restricted/Repetitive Behavior Criteria (must
have 2/4)
3. Highly restricted, fixated interests that are abnormal in intensity or focus,
such as:
• Strong attachment to or preoccupation with unusual objects
• Excessively circumscribed or perseverative interests

15. Restricted/Repetitive Behavior Criteria
(must have 2/4)
4. Hyper- or hyporeactivity to sensory input or unusual
interest in sensory aspects of the environment, such as
• Apparent indifference to pain/temperature
• Adverse response to specific sounds or textures
• Excessive smelling or touching of objects
• Visual fascination with lights or movement

16. What’s the change in criteria?
16
DSM-IV-
Autistic Disorder
Aspergers Disorder
PDD-NOS
Three symptom areas
– Social Interaction
– Communication
– Restricted repetitive and stereotyped patterns of
behavior, interests, and activities
Onset prior to age 3
DSM-5
Autism Spectrum Disorder
Two symptom areas
– Social Communication and
Interaction
– Restricted, repetitive patterns of
behavior, interests, and activities
Onset “during the early
developmental period”
DSM = Diagnostic and Statistical Manual
Lord et al. (2012)
American Psychiatric Association (2013)

17. Other problems
• Sensory problem
• Sleep problem
• Intellectual disability
• Seizures
• Gastrointestinal problems
• Other mental disorder

18. Severity level for ASD

19. Screening/Case finding
• All children should be screened for autism specific screening at 18 and
24 months of age in addition to Broad developmental screening at 9,18,
and 24 months
• Different screening tools have been developed
• Modified free checklist for autism in Toddlers (M-CHAT) autism specific tool
designed to identify children 16-30 months of age who should receive a more
thorough assessment for possible early signs of ASD or Developmental delay

24. Assessment
• If screening indicates ASD symptomatology, thorough diagnostic
assessment should be performed
• Multidisciplinary assessment is optimal in facilitating early
diagnosis, treatment
• All children with ASD should have a medical assessment

25. Treatment
• For young children, diagnosis and identification of treatment
programs will generally be the major focus
• For school age children, behavioral and medication issues will
often become priority
• For adolescence and early adulthood, vocational training along
with future self sufficiency planning

26. Psychosocial interventions
• Applied behavioral analysis(ABA)
• Early intensive behavioral intervention
• Early intensive behavioral intervention is intensive and highly
individualized with up to 40 hours per week of one to one direct
teaching
• Initially using discrete trials to teach simple skills and progressing
to more complex skills such as initiating verbal behavior.

27. • Older children and adolescents with relatively higher intelligence,
but with poor social skills and psychiatric symptoms, can benefit
from more intensive behavioral or cognitive-behavioral therapy
and/or supportive psychotherapy
• focus is on achieving social communication competence,
emotional and behavioral regulation, and functional adaptive
skills necessary for independence

28. • Structured educational models in children with ASD
• Early Start Denver Model
• Treatment and Education of Autism and related
Communication handicapped Children (TEACCH)
• Individualized educational plan (IEP) should reflect an
accurate assessment of the child’s strengths and
vulnerabilities with and explicit description of services to
be provided, goals and objectives, and procedures for
monitoring effectiveness

29. • Communication is generally addressed in the child’s IEP in
coordination with the speech-language pathologist
• Children who do not yet use words can be helped through
use of alternative communication modalities such as
• sign language,
• electronic communication boards,
• visual supports, picture exchange
• For individuals with fluent speech, the focus should be on
pragmatic (social) language skills training

30. Pharmacotherapy:
• Common targets include
• Comorbid conditions (anxiety, depression)
• Problematic target symptoms ( irritability, hyperactivity,
repetitive behavior, stereotypy, self-injurious behavior)

31. Complementary and Alternative
Treatments
• Many families seek complementary and alternative therapies for
ASD
• Complementary and alternative therapies for ASD are diverse,
ranging from biologically based therapies (eg, vitamin or
mineral supplements, special diets), to more invasive
treatments, such as hyperbaric oxygen treatments, chelation,
and injectable medications
6/29/2019
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33. 6/29/2019
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34. Prognosis
•Factors associated with positive outcomes
●Presence of joint attention
●Functional play skills
●Higher cognitive abilities
●Decreased severity of ASD symptoms
●Early identification
●Involvement in intervention
●A move toward inclusion with typical peers

35. • Factors associated with less favorable outcomes :
●Lack of joint attention by four years of age
●Lack of functional speech by five years of age
●Intelligence quotient (IQ) <70
●Seizures or other comorbid medical or
neurodevelopmental conditions
●Severe ASD symptoms

36. Reference
1. A. Marilyn, Autism spectrum disorder: Evaluation and diagnosis,
https://www.uptodate.com/contents/autism-spectrum-disorder-
evaluation-and-diagnosis
2. W. Laura, Autism spectrum disorder in children and adolescents:
Overview of management,
https://www.uptodate.com/contents/autism-spectrum-disorder-in-
children-and-adolescents-overview-of-management
3. Nelson Textbook of Pediatrics 20th edition
4. Essential Pediatrics, OP Ghai, 8th Edition