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SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS
Survey of Autism Spectrum Disorder Concerns
Presented by
Curtis L. Timmons, Ph.D., LSSP
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GOALS OF THE WORKSHOP
1. Understand why there were changes between the DSM-IV and the DSM-5
2. Understand the current criteria for
ASD
3. Video training to score ASD criteria
4. Developing an instrument to harvest diagnostic information
2
5. Understand other diagnoses which share traits with ASD
6. Review Case Studies
7. How to improve treatment team assessments
8. Completing the report
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SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS
* developmental delays
* intellectual limitations
* communication disorders,
* limited social skills,
* anxiety
4
DSM-5 requires functional impairments in two broad domains of concerns as well as
the majority of sub-domains.
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The predictive validity of most test instruments continue to reference membership to a group
that no longer meets diagnostic criteria.
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Social anxietyCommunication
Disorders
Sensory Processing difficulties
Intellectual limitations Developmental
DelaysAutism
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SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS
Thus, the predictive validity to the group that
meets the DSM-5 criteria may be quite low.
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FaFa Autism Spectrum Disorder
False positives
Incorrectly identified as
autism
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If new tests continue to
predict membership to
the previous group
ASDFalse positives
A simple cutoff score can not account for the options one must consider before concluding
the presence of ASD.
▪ All three Domain 1 criteria must be met.
▪ Two of the four Domain 2 criteria must be met.
▪ Symptoms are not better attributed to another mental health concern.
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SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS
SEVERITY LEVELS OF ASD
FUNCTIONAL INTERPETATION
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SEVERE:Requires Very
Substantial Support
Cannot function without one on one
supervision and assistance throughout
the day.
MODERATE:Requires Substantial
Support
Requires close proximity and redirection
throughout the day.
MILD:Requires Support
Requires ongoing awareness and coaching
of skills related to adjustment, behaviors
and relationships.
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Examples of Substantial Impact on Daily FunctioningSASDC: Interaction and
Observation Form ratingsLIMITED
COMMUNICATIONS AND
SOCIAL INTERACTION
DSM-5 DIAGNOSTIC
SEVERITY
Examples
5
Substantial
CAN NOT FUNCTION Nonverbal
Does not talk/interact with others
Intensely avoids and withdraws from all forms of interaction.
SEVERERequires very substantial support
4
Moderate to
substantial
SIGNIFICANT DISTRESS WITHIN
INTERACTIONS: Generally nonverbal,
Commonly upset by requirements to interact. Agitation, emotional meltdown
and withdrawal
MODERATERequires substantial support
3
Moderate
NOTABLE AVOIDANCE OF INTERACTION:
Prefers no interaction but can interact with
guidance and coaching.MILD
Requires support
SUBCLINICAL CONCERNS DO NOT MEET CRITERIA FOR ASD DIAGNOSIS2
Mild to moderate
PREFERENCE TO NOT INTERACT
with others. Has social skills to
interact yet often prefers solitary
activities. Can engage with other if
interested.
Not Clinical
1
Mild
LIMITED INTEREST IN OTHERS. Limited
social skills, Is somewhat indifferent to
others or often engaged in solitary play. Social skills are, otherwise, adequate
Not Clinical
0
Minimal
GOOD COMMUNICATIONS AND SOCIAL
SKILLS. Engages with others Joins activities
at developmental level Not Clinical
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Examples of Substantial Impact on Daily Functioning
SASDC: Interaction and Observation Form ratings
IMPACT ON DAILY FUNCTIONING
INTEREST IN DINOSAURS DSM-5
DIAGNOSTIC SEVERITY
Examples
5 Substantial
CAN NOT FUNCTION Emotionally Dependent: Melt-down if he does not have his favorite dinosaur
SEVERE Requires very substantial support
4 Moderate to substantial
OBSESSION: Knows the names of 12-20 dinosaurs, what they eat, their weight and their scientific name. Can only talk about dinosaurs.
MODERATE
Requires substantial support
3 Moderate
STRONGLY PREFERRED ACTIVITY: Only wants to play with dinosaurs. Difficulty transitioning to another activity. Theme of conversation generally involves dinosaurs.
MILD
Requires support
SUBCLINICAL CONCERNS; DOES NOT MEET CRITERIA FOR ASD DIAGNOSIS
2 Mild to moderate
Preferred Activity: Favorite toy, watches TV shows on dinosaurs. Knows some basic information regarding dinosaurs. Not an obsession of interest. Has other interests as well.
Not Clinical
1 Mild
Interest. Has several dinosaur toys. Can shift from this interest to other interests.
Not Clinical
0 Minimal
Passive Interest: Occasionally plays with dinosaurs and watches shows regarding dinosaurs.
Not Clinical
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SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS
ASD DOMAIN 1: Subdomain 1:Social-Emotional Reciprocity
1 Limited communications and social interaction 2 Does not have normal back-and-forth conversation
3 Does not share interests, thoughts, or emotions
4 Does not initiate social interactions
5 Does not respond to social interactions (return wave or smile)
6 Does not attempt to engage with others
7 Does not imitate others
8 Language is used to label/request rather than share feelings/converse
9 Does not perceive or understand social cues
10 Absence of speech
11 Repeats what others say in a mechanical fashion (echolalia)
12 Uses of words/phases do not fit the social situation
13 Awkward, mechanical or inappropriate manner of greeting and interacting
14 Language is developmentally delayed
15 Limited understanding of speech
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ASD DOMAIN 1: Subdomain 2:Nonverbal Communicative Behaviors
Used for Interaction
1 Does not make eye contact with others
2 Does not use gestures when communicating
3 Does not use facial expressions when communicating
4 Speech intonation is flat or mechanical in nature
5 Does not share interests with others
6 Does not understand others’ gestures
7 Body language is odd or unusual
8 Does not use nonverbal communications (pointing, sharing)
9 Poorly integrated eye contact, gestures & facial expressions
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ASD DOMAIN 1/Subdomain 3:Maintaining and Understanding Relationships
1 Does not understand how to maintain relationships
2 Does not understand how to interact with others
3 Does not use imagination in playing alone4 Has difficulties in making friends5 No interest in peers
6 Does not know how to join conversations
7 Conversation is one sided and only talks about special interest
8 Does not show awareness/interests in others
9 Rejection of others (hugs, attempts tointeract)
10 Passive or disconnected in relations
11 Aggressive or disruptive attempts to interact
12 No social play
13 Does not use imagination during play with others
14 Play follows precise rules or is otherwise very controlling
15 Does not understand what behavior is appropriate in a situation
16 Prefers to play alone
17 Prefers to interact with only younger or older people
18 Desires to play but does not understand how to do so
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SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS
ASD DOMAIN 2/Subdomain 1: Repetitive Motor movement/use of
objects/speech1 Unusual motor movements such as hand flapping, finger flicking,
rocking, twirling, spinning)
2 Unusual use of objects (lines up toys, spins/flips objects)
3 Unusual repetition of words/phrases
4 Frequent use of meaningless words or phrases
5 Frequently used words/phrases do not fit context of interaction
6 Use of “you” when referring to self
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ASD DOMAIN 2/Subdomain 2:Routines and Rituals
1 Insistence on sameness/routines
2 Cannot tolerate changes in routine
3 Extreme distress with small changes in routine
4 Exact repetition of verbal or nonverbal behavior
5 Difficulty with transition from one activity to another
6 Rigid thinking patterns (cannot tolerate differences)
7 Rigid rules of play or interaction
8 Tasks must be performed in a precise manner
9 Need to eat the same food every day
10 Need to take the same route every day
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ASD DOMAIN 2/Subdomain 3:Interests
1 Has a preoccupation with one or two specific interests
(dinosaurs, weather)
2 Strong attachment to a given object/toy
3 Preoccupation with a given object/toy
4 Perseveration of interests (does not change interests)
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SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS
ASD DOMAIN 2/Subdomain 4: Processing of Sensory Information
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1 Over reacts to sensory input (lights/sounds/textures)2 Under reaction to sensory input3 Overly focused on sensory stimuli (touch, smell, visual)4 Ritualistic behaviors involving tastes/smell/texture/food5 Indifference to extreme temperature (heat or cold)6 Overreaction to specific sounds7 Overreaction to specific textures 8 Excessive smelling of objects9 Excessive touching/feeling of objects
10 Visual fascination with lights 11 Visual fascination with movement/spinning objects12 Excessive food restrictions (eats only specific foods)13 Indifference to pain
Goals of developing an assessment instrument
• We also need to represent daily functioning rather than test-session adjustment.
• We need to represent information from two or more settings.
• We need to integrate clinical judgement into information from raters.
• We need to involve raters who are most familiar with the individual.
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The items for the SASDC are taken directly from the DSM-5
DSM-5
As the DSM-5 lists
a trait related to
ASD, the trait is converted to a SASDC item to be rated.
SASDC
Every item on the SASDC is presented
by the DSM-5™ as a diagnostic trait for
ASD.
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SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS
Concerns in developing the protocol
The protocol needs to be developed in such a manner that independent raters document concerns in two (or more) different settings.
(family ratings and teacher ratings)
We need account for similarities and differences in the ratings.
At times the rating may represent rater bias.
At times the ratings may represent different adjustment in different settings.
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Concerns in developing the protocol
Results of the ratings must be clearly presented to explain the various domains and subdomains.
The test scores can not be used as the sole determiner of a diagnosis of ASD. A cut-off score is not sufficient.
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Domain one has three subdomains. We can illustrate 1. the rating for each rater for each subdomain, present the average for each
subdomain, and show the average for each rater.P 83
T 85
O 0
A 84
P 73
T 67
O 0
A 70
P 82
T 63
O 0
A 73
P 79
T 72
O 0
A 76
Social-Emotional Reciprocity
Nonverbal Communications
and Interaction
Relationship Skills
AVERAGE SCORE FOR
COMMUNICATION
DOMAIN
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Teacher average
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SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS
The SASDC provides layers of confidence in meeting DSM-5 requirements
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Clinical Judgement and Alternative Diagnoses
Diagnostic Criteria Checklist
Interaction and Observation Form
Item Analysis
Subdomain Scores
Domain Scores
Composite Score
The DCC organizes our data:
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• Is there a prevalence of ASD traits?• Are there specific traits that are
consistently present?• Do traits cause substantial impact on
daily functioning?• Are the domain and subdomain
requirements met for an ASD diagnosis?
Let’s get back tocriteria C, D, and E.
Criteria C Based upon available history, were symptoms present in the early
developmental period?
Criteria D Based upon all sources of information available, do symptoms cause
clinically substantial impairment in social, occupational or other
important areas of functioning?
Criteria E Based upon expertise in rendering various psychological diagnoses, the
disturbance is not better explained by other mental health concerns,
intellectual disability or global developmental delay.
ASD Criteria Met
ASD Criteria Met
ASD Criteria Met
YESNO
YESNO
YESNO
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REQUIRES CAREFUL
CONSIDERATION AND
DELIBERATION
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SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS
Criteria E is the greatest challenge in offering an ASD diagnosis.
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According to the DSM-5…
you can not render an ASD diagnosis unless you have expertise in
rendering alternative diagnoses.
DIFFERENTIAL DIAGNOSES
To which diagnosis would you assign limited communications and social interaction?
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SELECTIVE MUTISM
√
MAJOR DEPRESSION
√
GLOBAL DEVELOPMENTAL
DELAYS
√
AUTISM
√
Mental health concerns that share traits with ASD.
Anxiety ADHD Bipolar Disorder Communication Disorders
Depression Disruptive Mood Dysregulation
Disorder
Global Developmental
Delay
Intellectual Disability
Oppositional Defiant Disorder
Personality Disorders
Post-traumatic Stress Disorder
Psychotic Disorders
Reactive Attachment
Disorder
Social (Pragmatic)
Communication Disorder
neurological problems Selective Mutism
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SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS
Other concerns that must be considered…
Medical problems
Mental Age Intellectual Age History of (seizures)
Birth trauma Head injuries History of abuse Mother’s use of alcohol and drug during pregnancy
Stability of the home
Previous social opportunities
Family’s mental health history
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Without considering other related concerns…
we are right back where we started…
misdiagnosis.
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ASD
DEVELOPMENTAL DELAYS
ANXIETY
RAD
SPCD
Sensory
Mental age
The DSM-5 states the following:
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.
The “well established” diagnosis suggests that this option is available
for only older teens/adults.
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SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS
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PRESENTING A FORMAL DIAGNOSIS
When you offer the diagnosis of ASD, provide a severity
rating for each of the two domains.
DSM-5 diagnosis: 299.00 Autism Spectrum Disorder
Social Communication and Social Interaction (moderate)
Restrictive and Repetitive Behaviors (moderate to severe)
Also use specifiers as follows:
With or without accompanying intellectual impairment
With or without accompanying language impairment
Associated with a known medical or genetic condition or environment factor
Associated with another neurodevelopmental, mental or behavioral disorder
With catatonia
A WORD ABOUT ASSESSSMENT TEAMS
The DSM-5 expert is responsible for seeing that
the DSM-5 criteria are met.
To include a review of
• previous diagnoses
• alternative diagnoses
• medications
• history of seizures
• history of head injuries
• Other neurodevelopmental
concerns.
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A WORD ABOUT ASSESSSMENT TEAMS
The diagnosis is not a group vote.
Other team members play a supportive role
according to their area of expertise.
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SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS
THANK YOU….
FOR MORE INFORMATION
On the internet:
SURVEY OF AUTISM SPECTRUM DISORDER CONCERNS (SASDC)
Autismtest-dsm5.com
Go 37
THANK YOU….
Workshops are available on:
• DSM-5 diagnoses
• Mental health concerns of children and teens
• Autism
• Building an ASD assessment team
• Survey of Autism Spectrum Disorder Concerns
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THANK YOU….
• Contact information
• Curtis L. Timmons, Ph.D., LSSP
• 254-751-9606
• email: [email protected]
Curtis Timmons, Ph.D.
6801 Sanger, #104
Waco, Texas 76710
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