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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.