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The Goal of DSM-5

Changes in DSM-5: Autism Spectrum Disorder and Social (Pragmatic) Communication Disorder Donald Oswald, PhD Commonwealth Autism Service. The Goal of DSM-5. APA DSM-5 workgroups formed in 2007 with the goals of: Creating a more “dimensional” classification system

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The Goal of DSM-5

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  1. Changes in DSM-5:Autism Spectrum Disorder andSocial (Pragmatic) Communication DisorderDonald Oswald, PhDCommonwealth Autism Service

  2. The Goal of DSM-5 • APA DSM-5 workgroups formed in 2007 with the goals of: • Creating a more “dimensional” classification system • Separating constructs of impairment and disorder (e.g., with the use of severity scales) • Reducing “-NOS” diagnoses in favor of broad categories with dimensional specifiers • Representing greater reflection of (and easier incorporation of) neurobiological findings • Gotham, K. (July 11, 2013). Autism Spectrum Disorder in DSM-5: Overview of Updates to the Diagnostic and Statistical Manual and to the Autism Diagnostic Observation Schedule (ADOS-2). Webinar hosted by the New Hampshire Autism Council Screening & Diagnosis workgroup

  3. Global Changes in DSM-5 • DSM-5 combines the first three DSM-IV-TR axes into one list that contains all mental disorders, including personality disorders and intellectual disability, as well as other medical diagnoses. • Contributing psychosocial and environmental factors or other reasons for visits are now represented through an expanded selected set of ICD-9-CM V-codes . . . • The DSM-5 includes separate measures of symptom severity and disability for individual disorders, rather than the Global Assessment of Functioning (GAF) scale. • APA. (2013). Insurance Implications of DSM-5

  4. Autism Spectrum Disorder • Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder NOS all subsumed under the diagnostic label Autism Spectrum Disorder; • CDD eliminated: “not being used” “age of onset specifier added” [actually just a more flexible age of onset criterion] • (http://www.psychiatry.org/practice/dsm/dsm5/dsm-5-video-series-changes-to-autism-spectrum-disorder) • Rett syndrome, if associated with ASD, is now specified as “known genetic condition”

  5. [Brief ICD-10 Digression] Pervasive developmental disorders • F84.0 - Autistic disorder • F84.2 - Rett'ssyndrome • F84.3 - Other childhood disintegrative disorder • F84.5 - Asperger's syndrome • F84.8 - Other pervasive developmental disorders • F84.9 - Pervasive developmental disorder, unspecified • Source: ICD-10-CM TABULAR LIST of DISEASES and INJURIES - 2014

  6. Symptom clusters “(A) qualitative impairment in social interaction” and “(B) qualitative impairments in communication” (from DSM-IV) “A. Persistent deficits in social communication and social interaction” (in DSM-5) The restricted repetitive behavior cluster is retained.

  7. Social-Communication Factor (Mandy et al., 2012) • In a sample of verbal children with social communication difficulties . . . • “The [two-factor] DSM-5 model [Social Communication (SC) and Restricted, Repetitive Behavior (RRB) ] was superior to the three-factor DSM-IV-TR model.” • “[At least] Among higher-functioning individuals, ASD is a dyad, not a triad, with distinct social communication and repetitive behavior dimensions.” • Pretty good empirical support for two-factor model.

  8. Autism Spectrum Disorder A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following currently or by history (examples are illustrative, not exhaustive): 1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back and forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

  9. Autism Spectrum Disorder (DSM-5) 2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body-language or deficits in understanding and use of gestures; to a total lack of facial expression and nonverbal communication. 3.    Deficits in developing, maintaining and understanding relationships, ranging, for example, 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.

  10. Digression Re: Criterion A • “The really fatal flaw here is that no instructions are given as to whether one item, two items, or all three items must be present to make the diagnosis of Autism Spectrum Disorder. “ • Allen Frances, chairman of the DSM-IV task force. (Blog, May 25, 2013)

  11. Autism Spectrum Disorder (DSM-5) B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of  the following, currently or by history (examples are illustrative, not exhaustive): 1.  Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).  2.  Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulty with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food everyday).

  12. Autism Spectrum Disorder (DSM-5) 3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). 4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights movement).

  13. Autism Spectrum Disorder (DSM-5) C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

  14. Specify if: With or without accompanying intellectual impairment With or without accompanying language impairment Associated with a known medical or genetic condition or environmental factor Associated with another neurodevelopmental, mental, or behavioral disorder With catatonia Catatonia?

  15. RE: Catatonia

  16. Specify if: With or without accompanying intellectual impairment With or without accompanying language impairment Associated with another neurodevelopmental, mental, or behavioral disorder With catatonia

  17. Severity levels for Autism Spectrum Disorder Level 1: "Requiring Support" Level 2: "Requiring Substantial Support" Level 3: "Requiring Very Substantial Support

  18. A Comment on Discrepant Conceptualizations of Severity in ASD (Weitlauf et al., 2013) • it is not clear how individuals with mixed levels of impairment across cognitive, adaptive, and autism-specific symptom domains would be classified in terms of DSM-5 ‘‘Level of Support’’ • [Should Level of Support . . .?] • be influenced by co-occurring symptoms and impairments that, although related to ASD, are not part of its core symptom profile[or] • indicate ‘‘level of support’’ for ASD symptoms alone (i.e., should not overlap with functional impairment)

  19. Issues with respect to Level of Support What are the psychometric properties of this scale? How will this characterization of individuals be used?

  20. Autism Spectrum Disorder in DSM-5 The DSM-5 allows dual diagnosis of ASD and AD/HD

  21. Autism Spectrum Disorder in DSM-5 "Note: Individuals with a well established DSM-IV 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."

  22. Impact of DSM-5(Frazier et al., 2012) “DSM-5 criteria had superior specificity relative to DSM-IV-TR criteria (0.97 versus 0.86); however sensitivity was lower (0.81 versus 0.95). Relaxing DSM-5 criteria by requiring one less symptom criterion increased sensitivity (0.93 versus 0.81), with minimal reduction in specificity (0.95 versus 0.97).” Retrospective, using existing assessment data

  23. Impact of DSM-5 • McPartlandet al. (2012), Matson, Belva et al. (2012), Matson, Kozlowski et al. (2012), and Worley and Matson (2012) . . . All of these studies show that according to the proposed algorithm, 30–45 % of children, adolescents, and adults classified with ASDs according to DSM-IV-TR criteria will not meet DSM-5 criteria for ASD. • Matson, Hattier, & Wiliams, 2012 • Utilizing combined ADOS/ADI-R data, 93 % of participants met DSM-5 criteria, which suggests likely continuity between DSM-IV and DSM-5 research samples characterized with these instruments in combination. • Mazefsky et al., 2013 • All retrospective, using existing assessment data

  24. DSM-5 Field trial • At Stanford . . . there were a total of 41 children who qualified for an autism spectrum disorder diagnosis under DSM-IV versus 36 with DSM-5 [88%]. But there were an additional 10 children who received a diagnosis of a newly proposed condition dubbed "social communication disorder" in the DSM-5 draft, which had no counterpart in DSM-IV. • Among the total of 46 who received diagnoses of autism spectrum or social communication disorders under DSM-5 were six who could not be diagnosed with anything under DSM-IV. • Reported response by Susan Swedo, MD, of the National Institute of Mental Health, head of the American Psychiatric Association committee rewriting the diagnostic criteria for autism spectrum disorders

  25. DSM-5 Field trial • . . .when the clinicians applied DSM-IV and DSM-5 criteria to the nearly 300 children included in the trial [across both sites], the autism spectrum prevalence was not changed much. • At Baystate Medical Center in Springfield, Mass., it increased a bit, to 25% with DSM-5 versus 23% with DSM-IV. At Stanford University in Palo Alto, Calif., it dropped to 20% from 26%. • Reported response by Susan Swedo, MD, of the National Institute of Mental Health, head of the American Psychiatric Association committee rewriting the diagnostic criteria for autism spectrum disorders

  26. Impact of DSM-5Barton et al. (2013) • In a sample of toddlers (n=422; Mean age = 25.76 months), the best algorithm required meeting only two (rather than three) of the DSM-5 social communication criteria and one (rather than two) of the repetitive behavior criteria. • In addition, the algorithm adopted a relaxed threshold for meeting the repetitive behavior criteria, meaning that a child’s repetitive behaviors could be less marked or less prototypical and still meet a criterion. • Conclusion: the DSM-5 symptom criteria for ASD, as currently conceptualized, are too restrictive to be acceptable for use with young children. • Retrospective study using existing assessment data

  27. Impact of DSM-5Gibbs et al., 2013 Prospective study 132 children and adolescents referred to a tertiary-level autism specific assessment service for an initial diagnostic assessment for autism DSM-IV-TR and DSM-5 diagnostic decisions were based on clinical judgment, informed by scores from the ADOS and ADI-R, information gathered from background reports and teachers or other professionals, results of previous cognitive assessments, information regarding academic functioning Twenty-six of the 111 children (23.4 %) who received a diagnosis under DSM-IV-TR did not meet criteria when considered under the proposed DSM-5 criteria.

  28. Impact of DSM-5Gibbs et al., 2013 Comparing those who did retain an autism diagnosis with those who did not, no significant difference regarding age or gender. “ . . . compared to those diagnosed with Asperger’s Disorder or Autistic Disorder [under DSM-IV-TR], a higher proportion [50%] of children with PDD-NOS under DSM-IV-TR [failed] to meet criteria under DSM-5” “It is possible that many of the children who would no longer meet ASD criteria under DSM-5 would instead meet criteria for a diagnosis of the proposed DSM-5 Social Communication Disorder (SCD).” [SCD not assessed in this study.]

  29. Impact of DSM-5Gibbs et al., 2013 “. . . of the 26 children who did not retain their DSM-IV-TR diagnosis under DSM-5, 14 failed to meet criteria under DSM-5 due to insufficient evidence of impairment in RRBs . . . 12 cases were sub-threshold in terms of the DSM-5 social communication domain, with the majority of this group (eight children) displaying largely intact use of nonverbal behaviors, both currently and according to historical record.” “. . . without any further changes, DSM-5 is likely to reduce the number of children who will be diagnosed with an ASD in the future due to the more stringent requirements. . .”

  30. Impact of DSM-5Young & Rodi 2013 Of the 210 participants in the present study who met DSM-IVTR criteria for a PDD [i.e., autistic disorder, Asperger’s disorder and pervasive developmental disorder-not otherwise specified (PDD-NOS)], only 57.1 % met DSM-5 criteria (specificity = 1.0) for autism spectrum disorder when criteria were applied concurrently during diagnostic assessment. High-functioning individuals (i.e., Asperger’s disorder and PDD-NOS) were less likely to meet DSM-5 criteria than those with autistic disorder. failure to satisfy all three criteria in the social-communication domain was the most common reason for exclusion (39 %).

  31. Some Questions What will be the impact of the “by history” qualifier? How will the DSM-5 criteria be applied in community settings?

  32. Impact of DSM-5 • “One might ask what . . . the actual impact of DSM-5 will be. The simple response is that we do not know.” • Volkmar& Reichow, 2013

  33. Autism Spectrum Disorder in DSM-5 "Note: Individuals with a well established DSM-IV 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."

  34. Social (Pragmatic) Communication Disorder A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following: • Deficits in using communication for social purposes, such as greeting and 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, such as speaking differently in a classroom than on a playground, talking differently to a child than to an adult, and avoiding use of overly formal language.

  35. Social (Pragmatic) Communication Disorder • (cont): 3. Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction. 4. Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meanings of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation.

  36. Social (Pragmatic) Communication Disorder B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination. C. The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities). D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of words structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder.

  37. Social (Pragmatic) Communication Disorder • ASD is characterized by 1) deficits in social communication and social interaction and 2) restricted repetitive behaviors, interests, and activities (RRBs). Because both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present. • APA (2013).Highlights of Changes from DSM-IV-TR to DSM-5.

  38. ASD and S(P)CD • S(P)CD criteria • Deficits in using communication for social purposes • Impairment of the ability to change communication to match context or the needs of the listener • Difficulties following rules for conversation and storytelling • Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meanings of language • ASD Social Communication criteria • Deficits in social-emotional reciprocity • Deficits in nonverbal communicative behaviors used for social interaction • Deficits in developing, maintaining and understanding relationships

  39. S(P)CD CritiqueNorbury, 2013 Diagnosis of SPCD is currently challenged by a lack of culturally valid assessment tools and a paucity of research evidence that the diagnostic criteria identify a coherent and persistent clinical condition. The existing evidence suggests that social communication and pragmatic language impairments are best conceived of as symptoms, rather than a diagnostic entity. In addition, social communication and pragmatic language impairments do not necessarily go together and therefore the requirement that both are present for diagnosis is untenable.

  40. Some Questions about S(P)CD Do these specific communication differences cluster together in nature? Does this combination exist in a ‘pure’ form, justifying a distinct diagnostic category, or only as difficulties that are invariably a part of some other condition? How will the education system handle the Social Communication Disorder diagnosis?

  41. Contact Information Donald Oswald, PhD Commonwealth Autism Service doswald@autismva.org

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