Download Randye Huron Keeping Current Autism 2015

KEEPING CURRENT:
AUTISM 2015
Randye F. Huron, MD
May 18, 2015
AUTISM AFTER DSM-5
DSM-5
AUTISM SPECTRUM DISORDER
• Eliminates PDD subtypes present in DSM-IV
and replaces with Autism Spectrum Disorder
• Diagnostic criteria has two domains of
impairment instead of three
ASD - DSM-5 CRITERIA
Current Conceptualization
Social
Communication
SocioEmotional
Reciprocity
Non-Verbal
Communication
Making
Relationships
Repetitive
Behaviors
Repetitive
Speech/
Movements
Routines
& Rituals
Fixed
Interests
Sensory
Concerns
SOCIAL COMMUNICATION CRITERIA
• Deficits in social-emotional reciprocity
• Deficits in nonverbal communication
behaviors used for social interaction
• Deficits in developing, maintaining and
understanding relationships
SOCIAL COMMUNICATION CRITERIA

Deficits in social-emotional reciprocity (from abnormal social
approach and failure of back-forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or respond to social
interactions)

Deficits in nonverbal communicative behaviors used for social
interaction (from poorly integrated v/nv communication to abnormalities
in eye contact and body language or deficits in understanding and use of
gestures; to a total lack of facial expressions and nonverbal communication)

Deficits in developing, maintaining and understanding
relationships (from difficulties adjusting behavior to suit various social
contexts; to difficulties in sharing imaginative play or in making friends; to
absences of interest in peers)
RESTRICTED, REPETITIVE PATTERNS OF
BEHAVIOR CRITERIA
• Stereotyped/repetitive motor movements, use of
objects, or speech
• Insistence on sameness, inflexible adherence to
routines, ritualized patterns of V/NV behavior
• Highly restricted, fixated interests that are
abnormal in intensity or focus
• Hyper or hyporeactivity to sensory input/ unusual
interest in sensory aspects of the environment
RESTRICTED, REPETITIVE PATTERNS OF
BEHAVIOR CRITERIA
 Stereotyped/repetitive motor movements, use of objects, or speech
(simple motor stereotypies, lining up toys or flipping objects, echolalia,
idiosyncratic phrases)
 Insistence on sameness, inflexible adherence to routines, ritualized
patterns of V/NV behavior (extreme distress at small changes, difficulties with
transitions, rigid thinking patterns, greeting rituals, need to take same route or eat
same food everyday)
 Highly restricted, fixated interests that are abnormal in intensity or focus
(strong attachment to or preoccupation with unusual objects, excessively
circumscribed or perseverative interests)
 Hyper or hyporeactivity to sensory input or unusual interest in sensory
aspects of environment (apparent indifference to pain/temp. adverse response
to specific sounds or textures, excessive smelling or touching of objects, visual
fascination with lights or movement)
DSM-5 CRITERIA
• Must meet all 3 social communication criteria
• Must meet 2 of 4 restricted, repetitive criteria
• Symptoms must be present during early
developmental period
• Symptoms cause clinically significant impairment
• Not better explained by ID/GDD
GENERAL GUIDELINES
• There are no specific guidelines where
symptoms should be classified within the DSM
criteria (which may contribute to variation in
diagnostic outcomes).
• Avoid using same behavior to satisfy two criteria.
• One example of a specific behavior may not be
sufficient to assign the criteria as present.
BEHAVIORS/SXS NO LONGER
CAPTURED
• Impairments in imaginative/symbolic play/lack
of functional play skills
• Speech language delays/language disorders
NEWLY RELEVANT to DSM-5
• Sxs can be currently or previously exhibited
• Deletion of age-of-onset criteria
• Stereotyped language part of the
repetitive/restrictive behavior domain
• Addition of sensory interests/aversions as a
criteria
• Addition of specifiers
DSM-5 criteria include specifiers about
severity.
Severity has been operationalized as the
degree of support required.
Support
Substantial support
Very substantial support
ASD SPECIFIERS
 With/without accompanying intellectual impairment
 With/without accompanying language impairment
 Associated with a known medical or genetic
condition/environmental factor
 Associated with another neurodevelopmental,
mental or behavioral disorder
 With catatonia
DSM SPECIFIERS
• Trying to capture meaningful heterogeneity
• Used to reflect co-morbidity accompanying ASD
• Language disorder and ID are the most relevant
(Dramatic change in proportion of indiv w/ ID & lang delays.)
(Language & IQ = strong predictors outcome and response to tx)
• Permissable to dx ADHD concurrently w/ ASD
• May have implications to prognosis & outcome
SOCIAL (PRAGMATIC)
COMMUNICATION DISORDER (SCD)
• New diagnosis for DSM-5.
• Children with impairing social deficits that
affect communication without repetitive
behaviors.
• SCD grouped with communication disorders.
SCD
• SCD may be suitable/alternative dx when new
DSM-5 criteria are not met.
• An assumption made that individuals with
these symptoms may have previously been
diagnosed with PDD-NOS.
• The intended purpose of SCD was to provide a
label/dx to help children get needed services
and treatment.
SOCIAL (PRAGMATIC)
COMMUNICATION DISORDER
• Deficits in using communication for social purposes
• Impairment of the ability to change communication
to match context or needs of the listener
• Difficulties following rules for conversation and
storytelling
• Difficulties understanding what is not explicitly
stated & nonliteral or ambiguous meanings of
language
SOCIAL (PRAGMATIC)
COMMUNICATION DISORDER
• Deficits in using communication for social purposes (greeting &
sharing information, in a manner that is appropriate for the social
context)
• Impairment of the ability to change communication to match
context or the needs of the listener (speaking differently in a
classroom than on a playground, talking differently to a child than an
adult, and avoiding use of overly formal language)
• Difficulties following rules for conversation and storytelling
(taking turns in conversation, rephrasing when misunderstood, and
knowing how to use V/NV signals to regulate interaction)
• Difficulties understanding what is not explicitly stated (making
inferences) and nonliteral or ambiguous meanings of language (idioms,
humor, metaphors, multiple meanings that depend on the context for
interpretation)
SCD DIAGNOSTIC CRITERIA
• Deficits result in functional limitations in effective
communication, social participation, social
relationships, academic achievement, or
occupational performance.
• The onset of symptoms is in the early
developmental period.
• The symptoms are not attributable to another
medical, neurological condition or language
problem and not better explained by ASD, ID,
GDD or another mental disorder.
SCD
• Sufficient language skills must be developed
before these higher-order pragmatic deficits
can be detected.
• SCD diagnosis should not be made until
children are 4 to 5 years of age.
• Requires ASD be ruled out.
HISTORY, HISTORY, HISTORY
• Clinical judgement remains the gold standard
in the diagnosis of ASD.
• Clinicians must collect high quality information
about behaviors relevant to an ASD diagnosis.
• Obtaining information from multiple sources is
critical in making a valid and reliable diagnosis
(therapists, teachers, EI assessments, schools
reports/evals, videos).
CASE REPORT
DISCUSSION
CASE REPORT
DISCUSSION
CHALLENGES WITH DSM-5
• Meeting all 3 social communication
criteria (may delay dx).
• Diagnosis/intervention in very young
children.
• Obtaining services without ASD dx (but
clearly having sxs/deficits).
EXPERIENCES
• Difficulty in dx young children – bringing them
back while providing early intervention services
• Noticing significant change in some young
children with services and time
• Getting behavior therapy without diagnosis
• Some clinicians clinging to DSM-IV
EXPERIENCES WITH SCD
• Some colleagues are starting to use SCD dx.
• Children with SCD receiving services:
speech/language tx and social skills group
• There is serious concern that indiv. dxed with
SCD may not have access to services and legal
supports provided with ASD dx.
IMPLICATIONS OF DSM-5
• DSM-5 increases specificity with an associated
cost in sensitivity.
• Retrospective analyses of ASD data indicate that
the majority of individuals with DSM-IV PDD
will continue to meet criteria for DSM-5 ASD
• Prospective studies needed to understand how
diagnoses of ASD will function in practice.
GRANDFATHER CLAUSE
DSM-5 states notes:
“Individuals with a well- established DSM-IV
diagnosis of autistic disorder, Asperger’s
disorder or PDD-NOS should be given the dx
of Autism Spectrum Disorder.”
“The dust is only beginning to settle
about the impact of DSM-5”
We are waiting to see the impact of DSM-5 in
regards to:
• Prevalence
• Effect on prior subgroups of PDD
• Public policy, state funded services, insurance
covered services for children in need of
services but do not have ASD dx
• Future research
THE FUTURE OF DSM-5
The reason why this version of DSM is
written as Arabic “5” rather than Roman “V”
is so it will be easier to create versions.
Expect to see DSM-5.1, 5.2…
As always, our goal continues to ensure
that our patients and their families’ needs
are met and that we provide them with
excellent clinical care and support.
THANK YOU