Autism Spectrum Disorders: Educational Implications of DSM-V

1. Welcome to… Autism Spectrum Disorders:Educational Implications of DSM-V with Steve Becker, Ph.D. Offered to the Washington State Association of School Psychologists Fall Conference, 2010

2. Today’s Program 9:00 A Framework for Understanding ASD A Brief History of ASD Classifications Current DSM-TR Classification Differential Diagnosis 9:45 Proposed DSM-V Criteria for ASD DSM-V: Cross-Cutting Dimensional Assessment DSM-V: Proposed ASD Criteria Issues in Classification DSM-V: Clinical Implications DSM-V: Questions 10:30 That’s all, folks!

3. The Umbrella Label of Pervasive Developmental Disorders Not Otherwise Specified PDD NOS Autistic Disorder PDD NOS ? Childhood Disintegrative Disorder (CDD) Rett’s Asperger’s Syndrome Other Conditions: Angelman Prader-Willi Williams

4. The “Autism Spectrum” X = Criterion met Mild (Asperger’s) (40%) Autism (Moderate) (50%) Autism (Severe) XXXXX X XXXXX X XXXXXX “On the Spectrum” X X X X X X Individuals vary greatly from one another on the “spectrum.”

5. Prevalence of Autism • Centers for Disease Control (December, 2009): • 1 in 110 children has autism (based on a 2006 study) • Rate for boys: 1 in 70 • Rate for girls: 1 in 375 • In 2000, the American Psychiatric Association identified a prevalence rate of about 1 in 500. • Does this increase reflect differences in better diagnostics/methodology or an increased frequency of autism?

6. A Brief History of ASD Classification-1 “Autism” comes from the Greek: “aut(o)”=self + “ism”: a state 1911: “Autism” used by Bleuler to mean active withdrawal into fantasy by schizophrenic patient 1919: Kraeplin: “Autistic personality”: “(They) reduce external interests and…[are notable for] their preoccupation with inward ruminations (precursor to schizoid personality).” 1943: Kanner: “Early Infantile Autism”: failure to develop relationships, lack of imagination 1944: Hans Asperger, Viennese physician: identified a pattern of lack of empathy, difficulty forming friendships, absorption in a special interest, and clumsiness. (Translated by Lorna Wing in the U.K. in 1983) 1950’s: Use of childhood schizophrenia, autism, and childhood psychosis as interchangeable (Laufer and Gair, 1969)

7. A Brief History of ASD Classification-2 • 1980: DSM-III: “Pervasive Developmental Disorders,” “Infantile Autism” • 1980’s/1990’s: Many children were diagnosed as ADHD, OCD, Oppositional, or “infantile autistic” but “Asperger’s” not widely used in U.S.-initial research in the U.K. • 1994: DSM-IV: autism and Asperger’s are separate classifications under category of PDD NOS. • Current Diagnosis: Asperger’s now generally considered High-Functioning (“HFA”) form of autism.

8. Diagnosis • There is no diagnostic test that yields hard evidence of autism. • Diagnosis is made from: • Rating scales: e.g.: Autism Diagnostic Observation Schedule, Gilliam Asperger’s Disorder Scale, Childhood Autism Rating, ABAS, SIB-R, Vineland • Behavioral observations (direct) • Social history • Personality Assessment (Children’s Apperception, Millon Adolescent or (Adult) Clinical Inventory) • Intelligence (Battelle, Wechsler, Stanford-Binet)

9. Differential Diagnosis-1 • Mental Retardation: • Asperger’s: not retarded; average/above-average range; testable • Autistic: functionally retarded but may understand everything; untestable by norm-referenced instruments • ADD/ADHD: • Asperger’s: overly focused on 1 activity • Autistic: inattentive to external stimuli • OCD: • Asperger’s: compulsive behaviors serve to reduce/escape social stress • Autistic: may have same function • Depression: Asperger’s: Higher prevalence Autistic: unknown

10. Differential Diagnosis-2 • Axis II Disorders • Schizoid Personality • Schizoids are cognitively impoverished and display an undifferentiated organization (Millon, 1994); Aspies display average or above-average intelligence with one focused interest. • Avoidant Personality • Avoidants distance themselves from intimate relations due to a fear of being judged (Millon, 1994); Aspies don’t care about being judged • Obsessive-Compulsive Personality • Obsessions: not present in Asperger’s • Compulsions: ritualistic handwashing and checking not prevalent

11. A Summary of DSM-TR Characteristics-1 Asperger’s: • Social interaction (2 of the following): • 1) Impairment in nonverbal communication: eye contact, facial expression, body language • 2) Failure to develop relationships with peers • 3) Lack of seeking others to share • 4) Lack of reciprocity • Stereotyped patterns (1 of the following): • 5) Preoccupation with 1 interest • 6) Adhering to non functional routines or rituals • 7) Stereotyped motor mannerisms • 8) Preoccupation with parts of objects • Other: • 9) Significant impairment in social, occupational, or other areas of functioning • 10) No delay in language • 11) No delay in cognitive, self-help, adaptive behavior

12. A Summary of DSM-TR Characteristics-2 Autistic (6 or more from 3 below, with 2 from Social Interaction and 1 from Communication, 1 from Restricted below): • Social interaction: • 1) Impairment in nonverbal communication: eye contact, facial expression, body language • 2) Failure to develop relationships with peers • 3) Lack of seeking others to share • 4) Lack of reciprocity • Communication: • 5) Delay or lack of spoken language • 6) Impairment of ability to sustain/maintain conversation • 7) Stereotyped or repetitive language • 8) Lack of spontaneous play or social contact • Restricted/Stereotyped patterns of behavior • 9) Preoccupation with an interest • 10) Inflexible adherence to routines • 11) Stereotyped , repetitive motor mannerisms • 12) Preoccupation with parts of objects

13. Proposal: DSM-V Cross-cutting Dimensional Assessment-1 • Cross-cutting assessment would “cut across” the boundary of any singular disorder • 2) Examples: mood, anxiety, substance use, sleep problems • 3) Cross-cutting Dimensional Assessment would provide • A] quantitative measures • B] a baseline measure of performance • C] a basis for measurement based care. • 4) Level 1 Assessments: 1-3 “clinically significant” items rated on a scale of 0-4 • Level 2 Assessments: clinician-rated measures

14. Examples of Cross-cutting Dimensional Assessment on ASD-2 5) Effects of Dimensional Assessment on differential diagnosis of autism spectrum disorders: A] Anxiety: HFA: low LFA: high B] Mood: HFA: often depressed LFA: agitated C] Affect: HFA: stable, constricted LFA: labile; self-stimulation/mutilation D] Substance use: HFA: very low LFA: very low E] Sleep disturbances: HFA: cycles LFA: very changeable

15. Changes in Proposed Diagnostic Criteria from DSM-TR to DSM-V-1 • Must meet criteria 1, 2, and 3: • Clinically significant, persistent deficits in social communication and interactions, as manifest by all of the following: • a. Marked deficits in nonverbal and verbal communication used for social interaction; • b. Lack of social reciprocity; • c. Failure to develop and maintain peer relationships appropriate to developmental level

16. Changes in Proposed Diagnostic Criteria from DSM-TR to DSM-V-2 2) Restricted, repetitive patterns of behavior, interests, and activities, as manifested by at least TWO of the following: a. Stereotyped motor or verbal behaviors, or unusual sensory behaviors b. Excessive adherence to routines and ritualized patterns of behavior c. Restricted, fixated interests 3) Symptoms must be present in early childhood (but may not become full manifest until social demands exceed limited capacities)

17. Differences Between DSM-TR and V • Elimination of “PDD NOS” and “Asperger’s Syndrome” as classifications • Asperger’s very different from low-functioning autism • What is “clinically significant?” • Does “unusual sensory behaviors” mean sensory-integration? • …or has not been correctly diagnosed

18. Issues with Classifications-1(adapted from American Psychiatric Association sources) • Asperger’s label does not work in clinics (Mayes, et al, 2001, Miller and Ozonoff, 2000) due to: • Children with Asperger’s do not meet the communication criterion of Autistic • Only a mildly positive correlation exists between clinician’s label and DSM-IV: .31) • Different research groups use different criteria • Research suggests early language criteria do not demarcate a distinct subgroup and are indistinguishable by school-age ( Macintosh and Dissanayake, 2004). • There is no clear evidence of an etiology. • Social acceptability of Asperger’s vs. Autism

19. Issues with Classifications-2(adapted from American Psychiatric Association sources) • 2) Research on Asperger’s is conflicting • Asperger’s is not substantially different from High-Functioning Autism (“HFA”) due to • 1] poor eye contact-A.(1) • 2] flat affect/facial expression-A.(1) • 3] lack of sharing with others-A.(1) • 4] lack of reciprocity-A.(1) • 5] abnormal preoccupation with a pattern of interest-A.(3) • 6] adherence to routines-A.1(3) • 7] preoccupation with parts of objects-A.1(3)

20. Issues with Classifications-3(adapted from American Psychiatric Association sources) • 3)Eligibility for services (e.g., Division of Developmental Disabilities (DDD) vs. Division of Vocational Rehabilitation (DVR) • DDD: not eligible; must have IQ<70 • DVR: is eligible • 4)Confusion/Duplication of terms • A] Is Asperger’s the same as HFA? PDD NOS? • B] Would dropping of Asperger’s constitute an “attack” on an Aspie’s identity? Is the label “autism” overly stigmatizing (i.e., mixing HFA’s with normal IQ’s or LFA’s with intellectually disabled?) • C] Do autism and Asperger’s mean different things? Or do they occur along a continuum? • D] Would there be more focus on milder forms, such as research and treatment?

21. Issues with Classifications-4(adapted from American Psychiatric Association sources) • 5) Parental and Adult Resistance • A] Major difference between Asperger’s and autism • B] Autism more stigmatizing-> lower self-esteem • C] Inhibit recent progress on awareness of Asperger’s by the public • D] May inhibit mildly affected from being assessed for autism (“A Powerful Identity, a Vanishing Diagnosis, by Claudia Wallis, November, 2009). • E] Will students with High IQ (HFA) be placed with students with LFA? • 6) “False epidemic” of autism (Dr. Allen Frances, Psychiatric Times, January, 2010)

22. Other Educational Implications in Diagnosis for “Autistic Disorder” • Elimination of “Asperger’s Disorder” (299.80) and “Pervasive Developmental Disorder” (“PDD NOS”) as classifications • Inclusion of unusual sensory behaviors • Would define 2 core elements: impaired social communication and repetitive behaviors or fixed interests 4) A child with autism could not also be diagnosed with ADHD.

23. Questions Arising from the Proposed ASD Criteria • Will mildly affected (“Aspies”) avoid evaluation and treatment due to stigma of autistic?” • Will Aspies self-esteem be negatively impacted? • A child with autism could not also be diagnosed with ADHD. • Will insurance companies cover HFA? • Will use of inconsistent labels stop? (Autistic? PDD NOS?) • Who will qualify for state services? • How to measure severity with uneven profiles of abilities (e.g., intelligence, verbal language). • Will one unified category lead to better services?

24. References Asperger, Hans. (1944). “Die Autistischen Psychpathen.” Archiv fur Psychiatrie und Nervenkrankheiten. 117:76-136. Atwood, Tony. (1998). Asperger’s Syndrome. Jessica Kingsley Publishers: London, England. Bleuler, E. (1911). “Dementia preacox oder gruppe der schiozophrenien.” Translated by Zinkin, J. New York: International University Press. Frances. A. (2009). “Alert to the research community-be prepared to weigh in on DSM-V,” Psychiatric Times. 27:2. Kanner, Leo. (1943). “Autistic disturbances of affective contact.” Nervous Child 2:217-250. Kraeplin, E. (1919). “Dementia preacox and paraphilia,” Livingstone: Edinburgh, Scotland. Laufer, M.W., and Gair, D.S. (1969). “Childhood Schizophrenia.” In L. Bellak and L. Loeb (Eds.) The Schizophrenic Syndrome. Grune and Stratton: New York. Macintosh, K.E., and Dissanaayake. (2004). Annotation: The similarities and differences between autistic disorder and Asperger’s disorder: a review of the empirical evidence. Journal of Child Psychology and Psychiatry., 45, 421-434. Mayes, S.D. Calhoun, S.L., and Crites, D.L. (2001). Does DSM-IV Asperger’s Disorder exist? Journal of Abnormal Child Psychology. 29:263-271. MillerJ.N., and Ozonoff, S. (2000). The external validity of Asperger Syndrome: Lack of evidence from the domain of neuropsychology. Journal of Abnormal Psychology, 109: 227-238. Millon, T. (2000). Personality Disorders in Modern Life. John Wiley and Sons: New York. • Rutter, M. and Schopler, E. (1979). Autism: A Reappraisal of Concepts and Treatment. Plenum Press: New York. • Wallis, C. “A powerful identity, a vanishing diagnosis,” The New York Times. November 3, 2009.

25. Bibliography-1 American Psychological Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Washington, DC. American Psychological Association. Attwood, T. (1998). Asperger’s Syndrome: A Guide for Parents and Professionals. Philadelphia. Jessica Kingsley Publishers. Attwood, T. (2004). Exploring Feelings: Cognitive Behavior Therapy to Manage Anxiety. Arlington, TX. Future Horizons. Attwood, T. (2007). The Complete Guide to Asperger’s Syndrome. London. Jessica Kingsley Publishers. Baker, B.L., & Brightman, A.J. (2004). Steps to Independence: Teaching Everyday Skills to Children with Special Needs. (4th ed.). Baltimore. Paul Brookes Publishing Company. Baker, J.E. (2003). Social Skills Training for Children and Adolescents with Asperger Syndrome and Social-Communication Problems. Shawnee Mission, KS. Autism Asperger Publishing Company. Baker, Jed. (2001). The Social Skills Picture Book: Teaching Play, Emotion, and Communication to Children with Autism. Arlington, TX. Future Horizons. Baron-Cohen, S. (2004). Mind Reading: An Interactive Guide to Emotions. London. Jessica Kingsley Publishing. Bellini, S. (2006). The Autism Social Skills Profile. Shawnee Mission, KS. Autism Asperger Publishing Company. Bellini, Scott. (2006). Building Social Relationships: A Systematic Approach to Teaching Social Interaction Skills to Children and Adolescents with Autism Spectrum Disorders and Other Social Difficulties. Shawnee Mission, KS. Autism Asperger Publishing Company. Cater, M, and Santomauro, J. (2007). Pirates: An Early-Years Group Program for Developing Social Understanding and Social Competence for Children with Autism-Spectrum Disorders and related Challenges. Shawnee Mission, KS. Autism Asperger Publishing Company.

26. Bibliography-2 Csoti, M. (2001). Social Awareness Skills for Children. Philadelphia. Jessica Kingsley Publishing. Elias, M.J., Butler, L.B., Bruno, E.M., Papke, M.R., & Shapiro, T.F. (2005). Social Decision Making/Social Problem Solving: A Curriculum for Academic, Social, and Emotional Learning. Champaign, IL. Research Press. Gajewski, N., Hirn, P., & Mayo, P. (1998). Social Skill Strategies: A Social-Emotional Curriculum for Adolescents. (2nd ed.). Eau Claire, WI. Thinking Publications. Grandin, Temple, and Barron, Sean. (2005). Unwritten Rules of Social Relationships. Future Horizons. Gray, C. (2000). The New Social Story Book: Illustrated Edition. Arlington, TX. Future Horizons. Gray, C., & White, A.L. (2002). My Social Stories Book. Philadelphia. Jessica Kingsley Publishers. Gutstein, S.E. & Sheely, Rachelle K. (2002). Relationship Development Intervention with Children, Adolescents, and Adults: Social and Emotional Development Activities for Asperger Syndrome, Autism, PDD and NLD. London. Jessica Kingsley Publishers. Gutstein, S.E. & Sheely, Rachelle K. (2002). Relationship Development Intervention with Young Children. London. Jessica Kingsley Publishers. Klin, A., Volkmar, F.R., & Sparrow, S.S. (2000). Asperger Syndrome. New York. The Guilford Press. Knapczyk, D., & Rodes, P. (2001). Teaching Social Competence: Social Skills and Academic Success. Verona, WI. IEP Resources. Lieberman, L.A. (2005). A “Stranger” Among Us: Hiring In-Home Support for a Child with Autism Spectrum Disorders or Other Neurological Differences. Shawnee Mission, KS. Autism Asperger Publishing Company McAfee, Jeanette. (2002). Navigating the Social World: A Curriculum for Individuals with Asperger’s Syndrome, High Functioning Autism and Related Disorders. Arlington, TX. Future Horizons, Inc. Myles, B.S., Cook, K.T., Miller, N.E., Rinner, L., & Robbins, L.A. (2000). Asperger Syndrome and Sensory Issues: Practical Solutions for Making Sense of the World. Shawnee Mission, KS. Autism Asperger Publishing Company.

27. Bibliography-3 Smith, C. (2003). Writing and Developing Social Stories: Practical Interventions in Autism. Oxon, UK. Speechmark Publishing, Ltd. Wagner, S. (1998). Inclusive Programming for Elementary Students with Autism. Arlington, TX. Future Horizons, Inc. Waltz, Mitzi. (1999). Pervasive Developmental Disorders. O’Reilly and Associates. About/For Adults: Becker, Steve. (2003). Living with Asperger’s: The Aspie’s Guide to Friendships. Seattle, WA. Capital City Publishing. Grandin, T., and Scariano, M. (1986). Emergence: Labeled Autistic. Novato, California. Arena Press. Lawson, Wendy. (2003). Build Your Own Life. London. Jessica Kingsley Publishers. Lovett, J. (2005). Solutions for Adults with Asperger’s Syndrome. Gloucester, MA. Quayside Publishing. Willey, L. (1999). Pretending to bo Normal. London. Jessica Kingsley Publishers. Zaks, Z. (2006). Life and Love: Positive Strategies for Autistic Adults. Shawnee Mission, KS. Autism Asperger Publishing Company.

28. Bibliography (page 4) Family Reading: Harris, S. (1994). Siblings of Children with Autism. Bethesda, Md. Woodbine House. Ives, Martine, and Munro, Nell. (2002). Caring for a Child with Autism. London. Jessica Kingsley Publishers. Johnston-Tyler, J. (2007). The Mom’s Guide to Asperger’s Syndrome. Shawnee Mission, KS. Autism Asperger Publishing Company. Myles, B.S., & Southwick, J. (2005). Asperger Syndrome and Difficult Moments: Practical Solutions for Tantrums, Rage, and Meltdowns. (Rev. ed.). Shawnee Mission, KS. Autism Asperger Publishing Company. Myles, B.S., Trautman, M.L., & Schelvan, R.L. (2004). The Hidden Curriculum: Practical Solutions for Understanding Unstated Rules in Social Situations. Shawnee Mission, KS. Autism Asperger Publishing Company. Newport, J, and M. (2002). Autism-Asperger’s and Sexuality. Arlington, Tx. Future Horizons. Ozonoff, S., Dawson, G., and McPartland, J. (2002). A Parent’s Guide to Asperger’s Syndrome and High-Functioning Autism. New York. Guilford Press. Pyles, L. (2002). Hitchhiking through Asperger’s Syndrome. London. Jessica Kingsley Publishers. Pratt, C. (2000). Peer Support Programs. Bloomington. Indiana Resource Center for Autism Training. Quill, K. (2000). Do-Watch-Listen-Say: Social and Communication Intervention for Children with Autism. Baltimore. Brookes Publishing. Sicile-Kira, Chantal. (2004). Autism Spectrum Disorders. Perigee. Vicker, Beverly. (2007). Sharing Information about Your Child with Autism Spectrum Disorder: What Do Respite or Alternative Caregivers Need to Know? Shawnee Mission, KS. Autism Asperger Publishing Company. Willey, L. (2001). Asperger’s Syndrome in the Family. London. Jessica Kingsley Publishers.

29. Bibliography (page 5) Books for Kids: Bolick, Teresa. (2001). Asperger’s Syndrome and Adolescence. Gloucester, MA. Future Horizons. Buron, K.D. (2006). When My Worries Get Too Big! Shawnee Mission, KS. Autism Asperger Publishing Company. Faherty, Catherine. (2000). Aspergers…What Does It Mean to Me? A Workshop Explaining Self-Awareness and Life Lessons to the Child or Youth with High Functioning Autism or Aspergers. Arlington, TX. Future Horizons, Inc. Jaffee, A., & Gardner, L. (2006). My Book Full of Feelings. Shawnee Mission, KS. Autism Asperger Publishing Company. Keating-Velasco, J. A is for Autism, F is for Friend. (2007). Shawnee Mission, KS. Autism Asperger Publishing Company. Levine, Caroline. (2007). Jay Grows an Alien. Shawnee Mission, KS. Autism Asperger Publishing Company.

30. About Steve Becker… • Dr. Steve Becker has worked for over 30 years with clients with autism, Asperger’s Syndrome, and severe disabilities. • Following a 12-year career as a Job Coach and with disabled adults, Steve has offered school consultations for applied behavior analysis, IEP/program development, and social skill classes since 1985. He is a member of the Professional Advisory Board of the Autism Society of Washington and the Washington State Psychological Association. • You can reach him at (206) 935.2479, or at stevebecker7@comcast.net www.stevebeckerassociates.com