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Diagnostician
Workshop
Community of Practice
June 20, 2013
Learning Objectives
• Review DSM-5 criteria and discuss in small
groups
• Practice applying criteria to 3 different
cases
• Practice using new diagnostic recording
procedures for 1 case
• Discuss whether and how diagnostic
assessment procedures will change as a
result of DSM-5
General diagnostic
considerations
• Individuals may have adequate communicative
skills in separate communicative behaviors, but
integration may be limited
• Consider behavioral symptoms in relation to
norms for age, gender and culture
• The stage when behavioral differences become
evident may vary from person to person based
on the individual and environment
General diagnostic
considerations (continued)
• Difficulties may be “masked” in at least
some situations by skills acquired through
intervention, current supports
• Criteria may be met based on descriptions
of historical behavior
• Impairments exceed difficulties expected
based on the individual’s developmental
level
Some Points of Interest
• Diagnostic criteria can be met currently or by
history
• Must meet all 3 criteria in social interaction and
social communication domain
• Severity ratings
• Addition of sensory over- or underresponsiveness to RRB domain
• Stereotyped language, echolalia, and
idiosyncratic language now fall under RRB
And a few more…
• Removal of 2A (delay or lack of language)
• Removal of 2D (lack of varied, spontaneous
make-believe play or social imitative play)
• Symptoms may not be (or have been) fully
apparent “until social demands exceed limited
capacities, or may be masked by learned
strategies in later life”
Severity specifiers (p. 52)
• Recorded separately for social communication
and restricted, repetitive behaviors
• Focus on level of functioning and need for
support
• “The descriptive severity categories should not
be used to determine eligibility for and provision
of services; these can only be developed at an
individual level and through discussion of
personal priorities and targets” (p. 51)
• Severity may fall below Level 1 (p. 51)
No “take-backs”
“Individuals with a well-established diagnosis of
autistic disorder, Asperger’s disorder, or pervasive
developmental disorder not otherwise specified
should be given the diagnosis of autism spectrum
disorder. Individuals who have marked deficits in
social communication, but whose symptoms do
not otherwise meet criteria for autism spectrum
disorder, should be evaluated for social
(pragmatic) communication disorder.”
--- DSM-5, p. 51
ASD and Global Developmental
Delay
• “A diagnosis of autism spectrum disorder in an individual
with intellectual disability is appropriate when social
communication and interaction are significantly impaired
relative to the developmental level of the individual’s
nonverbal skills (e.g., fine motor skills, nonverbal
problem solving). In contrast, intellectual disability is the
appropriate diagnosis when there is no apparent
discrepancy between the level of social-communicative
skills and other intellectual skills.” (p. 58)
• May be very difficult to differentiate in very young
children
ASD and ADHD
• ADHD symptoms are commonly observed
in people with ASD
• In DSM-5: “When criteria for both ADHD
and autism spectrum disorder are met,
both diagnoses should be given.” (p. 58)
Social (Pragmatic)
Communication Disorder
• Problems in social communication without RRB
• Superseded by ASD diagnosis when RRB criteria (current
and/or historical) are met
Social Communication
Disorder Criteria
• Criteria include:
• Deficits in using communication for social purposes
appropriate for social context
• Impairment of ability to change communication to
match social context or needs of the listener (includes
use of overly formal language)
• Difficulties following rules for conversation and
storytelling
• Difficulties understanding what is not explicitly stated
and nonliteral or ambiguous meanings of language
GOODBYE, MULTIAXIAL
SYSTEM…
AND HELLO, SPECIFIERS…
Recording Procedures
• Code 299.00
• Autism Spectrum Disorder
Recording Procedures
• Note if the ASD occurs in association with
• a known genetic condition: e.g., Rett syndrome, FraX,
Down syndrome, tuberous sclerosis
• medical disorder: e.g., epilepsy
• history of environmental exposure: e.g., valproate,
fetal alcohol syndrome, very low birth weight
• another neurodevelopmental disorder: e.g., ADHD,
conduct disorder
• mental disorder: e.g., anxiety, depressive disorder
• behavioral condition: e.g., feeding, elimination, sleep
disorders
299.00 Autism spectrum disorder
associated with Down syndrome, epilepsy,
attention-deficit/hyperactivity disorder,
and self-injury
Recording Procedures
• Record the severity of social
communication and restricted, repetitive
behaviors
• “requiring [level of] support for deficits in
social communication and requiring [level
of] support for restricted, repetitive
behaviors”
299.00 Autism spectrum disorder
associated with Down syndrome, epilepsy,
attention-deficit/hyperactivity disorder, and
self-injury requiring very substantial
support for deficits in social
communication and requiring substantial
support for restricted, repetitive behaviors
Recording Procedures
• Specify with or without “accompanying intellectual
impairment”
• Specify with or without “accompanying language
impairment”. This element includes further specification of
the nature of the impairment, e.g., “no intelligible speech”,
“phrase speech”, or “fluent speech”
• NOTE: attention to both receptive and expressive skills should
be given in assigning this specifier
• “If catatonia is present, record separately ‘catatonia associated
with autism spectrum disorder.’”
299.00 Autism spectrum disorder associated with
Down syndrome, epilepsy, attentiondeficit/hyperactivity disorder, and self-injury
requiring very substantial support for deficits in
social communication and requiring substantial
support for restricted, repetitive behaviors with
accompanying intellectual impairment and with
accompanying language impairment – phrase
speech
WILL THERE BE A NEED TO
CHANGE DIAGNOSTIC
PROCEDURES?
“Best Practice Recommendations for
Assessment and Diagnosis”
• Wisconsin Community of Practice on Autism Spectrum
Disorders and Developmental Disabilities – ASD Diagnostic
Workgroup
• Critical domains:
• Hearing/Audiology
• Developmental history and current developmental/cognitive
functioning
• Language and communication
• Adaptive behavior
• Structured and unstructured assessment of autism symptoms
through interview and observation
• Assessment of co-morbidities to enable differential diagnosis
“Best Practice Recommendations”:
Methods
• Detailed interview re: developmental, medical, family,
educational, and intervention history
• Standardized assessments
•
•
•
•
Developmental level/IQ
Adaptive behavior
Speech and language
Hearing/audiology
• Detailed assessment of current autism symptoms
• Minimum: interview/review of DSM criteria; Optimal: ADI-R
• Minimum: observation (e.g., CARS-2); Optimal: ADOS-2
• Detailed interview re: additional symptoms, co-morbidities
• Consider referrals to other specialists, e.g. medical genetics,
neurology, gastroenterology, sleep specialists, etc.