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!Impact of the DSM-5 Criteria for ASD Community Update - May 2013By Katie Weisman, for the SafeMinds Research Committee

Introduction

This month, the American Psychiatric Association will publish the latest edition of its Diagnostic and StatisticalManual the DSM-5. The manual contains significant changes to the diagnostic criteria for individuals with autism.

1. The name of the category will be changed from Pervasive Developmental Disorder to Autism Spectrum Disorder.

2. The four previous diagnoses: Autistic Disorder, Aspergers Syndrome, Pervasive Developmental Disorder- Not

Otherwise Specified and Childhood Disintegrative Disorder will all be combined into the single category of Autism

Spectrum Disorder. Rett Disorder will be eliminated from the manual since the gene that causes it has been

identified.

3. Three symptom domains will be reduced to two by combining the speech and social symptoms into a single

category. The number of criteria has been reduced from 12 to 7.

4. Severity codes will be added for each symptom domain, though the details are unclear at this time on how

severity will be judged.

CriteriaThe new criteria under the DSM-5 are as follows:

Autism Spectrum Disorder

Currently, or by history, must meet criteria A, B, C, and D:

A. All individuals must have or have had persistent deficits in social communication and social interactionacross contexts, not accounted for by general developmental delays, and manifest by all 3 of thefollowing:

1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure ofnormal back and forth conversation through reduced sharing of interests, emotions, and affectand response to total lack of initiation of social interaction,

2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly

integrated- verbal and nonverbal communication, through abnormalities in eye contact andbody-language, or deficits in understanding and use of nonverbal communication, to total lack offacial expression or gestures.

3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyondthose with caregivers); ranging from difficulties adjusting behavior to suit different socialcontexts through difficulties in sharing imaginative play and in making friends to an apparentabsence of interest in people

B. All individuals must have or have had restricted, repetitive patterns of behavior, interests, or activitiesas manifested by at least two of the following:

1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motorstereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).

2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessiveresistance to change; (such as motoric rituals, insistence on same route or food, repetitivequestioning or extreme distress at small changes).

3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strongattachment to or preoccupation with unusual objects, excessively circumscribed orperseverative interests).


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4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment;(such as apparent indifference to pain/heat/cold, adverse response to specific sounds ortextures, excessive smelling or touching of objects, fascination with lights or spinning objects).

C. Symptoms must be present in early childhood (but may not become fully manifest until social demandsexceed limited capacities)

D. Symptoms together limit and impair everyday functioning.

In addition, the DSM-5 introduces a new disorder, not on the autism spectrum, with the following criteria:

Social Communication Disorder

A. Social Communication Disorder (SCD) is an impairment of pragmatics and is diagnosed based on difficulty in the

social uses of verbal and nonverbal communication in naturalistic contexts, which affects the development of social

relationships and discourse comprehension and cannot be explained by low abilities in the domains of word structure

and grammar or general cognitive ability.

B. The low social communication abilities result in functional limitations in effective communication, social

participation, academic achievement, or occupational performance, alone or in any combination.

C. Rule out Autism Spectrum Disorder (ASD). Autism Spectrum Disorder by definition encompasses pragmatic

communication problems, but also includes restricted, repetitive patterns of behavior, interests or activities as part of

the autism spectrum. Therefore, ASD needs to be ruled out for SCD to be diagnosed.

D. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed

limited capacities).

Social Communication Disorder will be the diagnosis for anyone who meets all three of the Autism Spectrum Disorderspeech and social criteria but none of the repetitive and restrictive behavior criteria. There is currently a gap betweenASD and SCD, with no clear diagnosis for someone with all three speech/social domain criteria but only one criteriaunder the restricted and repetitive behavior/sensory domain.

!Research SummaryFurther studies are in process, but at this point, it is fair to expect that the result of the DSM-5 criteria will be

a reduction of ASD diagnoses of at least 20% relative to the DSM-IVTR criteria. The data supports that thelargest reductions will be in those formerly diagnosed with PDD-NOS. What remains completely unknown is

whether a portion of that reduction will be compensated for by cases that the DSM-5 identifies that would not have

met the DSM-IVTR criteria. However, the only data showing an actual increase in ASD diagnoses overall was the

field trials which involved only 83 children at two clinical sites and included no toddlers or adults. The only other

study reporting a substitution effect was Wilson et al., 2013 which showed a 21% reduction vs. DSM-IVTR even

after allowing for the additions from DMS-5 picking up extra cases.

RecommendationsFor Parents:

1) Document your childs history so that if something happens to you there will be a record of symptoms your child

had in the past. Keep a folder with all previous professional evaluations in one place in case your child needs to be

re-assessed using the new criteria.2) For parents seeking a new diagnosis, recognize that a toddler may not obviously meet the new criteria. Be sure

that both the ADOS and ADI-R are used along with a detailed history, if at all possible but keep in mind that these

assessments will likely be updated to reflect the new criteria. If that isnt possible, be sure to make a complete list,


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before the evaluation, of all behaviors your child exhibits. Note ways in which these behaviors impact your childs

functioning.

3) If your child is one that may be diagnosed with Social Communication Disorder, document any speech issues that

your child has and ask for a dual diagnosis along with an established speech language disorder in order to leave no

question about speech services eligibility. Use the SCD diagnosis to advocate for additional social components to

your childs program.

Below is a chart summarizing the studies to date with regard to the comparison between the current DSM-5 and

DSM-IVTR criteria.

Authors Diagnoses

Included

Sample

Size

Breakdown

by Diagnosis

Age

Range

Overall

ASD %

Change

(Decrease)

AD %

Change

PDD-

NOS

%

Change

Aspergers

% Change

McPartland

Volkmar

AD

PDD-NOS

Aspergers

657 450

159

48

1-43 yrs.

Mean 9.2

(39.4%) (24.2) (71.7) (75)

Matson

et al.

AD

PDD-NOS

795 453

342

17-36

Months

(47.8%) (24.3) (79.9) N/A

Worley

Matson

N/A 180 N/A 3-16 yrs.

Mean 8.3

(32.3%)

Gibbs

Et al.

AD

PDD-NOS

Aspergers

111 59

34

18

2-16

Years

Mean 6.1

(23.4%) (10.2) (50) (16.6)

Taheri

Perry

AD

PDD-NOS

131 93

36

2.8-12.6

Years

Mean 6.4

(37%) (19) (83) N/A

Field Trials AD

PDD-NOS

Aspergers

79 35

23

21

6-17 yrs.

Approx.

Mean 12

(19%) or

5% increase

See notes

above

Mazefsky

et al.

AD

PDD-NOS

Aspergers

498 All three

diagnoses

were treated

as one group.

5-61 yrs.

Mean

21.8 yrs

Mean IQ

105

(0-7%) With the caveat that both the ADOS and the

ADI-R be used together, including the non-algorithm

ADI items for RRBS. Without the caveat, the drop in

overall ASD diagnosis using the DSM-5 was an 11-

14% drop. Using the ADI-R alone gave a 17% drop.


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Turygin

et al.

ASD

(DSM-

IVR)

ASD

(DSM-IVR

+ DSM5)

2054 278

279

17-36

months

This study was designed to look at the levels of

impairment of toddlers with DSM-IVR vs. DSM-

IVR+DSM-5 diagnoses and other DD children. It

found that toddlers who also met both sets of criteria

had more difficulties on various measures of the

Battelle Developmental Inventory than toddlers who

only met the DSM-IVR criteria.

Huerta

Et al.

See notes

AD

PDD-NOS

Aspergers

4453 3221

971

251

2-17.11

Yrs.

Mean

6.4-9.4

3 sites

(9%)

Beighley

Et al.

AD

PDD-NOS

Aspergers

328 Not given 2-18

Yrs.

Mean

8.01

(33.2%) Challenging behaviors were more

similar between the ASD groups

diagnosed by the DSM-IVTR criteria

vs. the DSM-5 criteria than they were

to controls who met neither set of

criteria.

Wilson

Et al.

AD

PDD-NOS

Aspergers

80 Not given 18-65

Yrs.

Mean 31

(24%) using

DSM-IVTR

(44%) vs.

ICD-10R

Barton

Et al.

AD

PDD-NOS

Aspergers

284 Not given 16.8-

39.4

Months

Mean

25.8

Months

Sensitivity of the DSM-5 criteria for

toddlers did not get to .90 until the

algorithm was relaxed to 2 of 3

speech/social behaviors and 1 of 4

RRB behaviors.

!!For more information and the full version of this article, please visit www.SafeMinds.org


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DSM-IV TR (current standard) DSM-5 (May, 2013)

2012 Steve Kossor Permission to duplicate is granted to parents and their advocates www.ibc-pa.org www.TreatmentPlansThatWorked.com www.OurCaseManager.pro 610-212

"Pick Six" "All Four Required"

Impaired social interaction (two required) Impaired social and communicative interaction (all three required)Reciprocity, nonverbal behavior, relationships, shared interests Reciprocity, nonverbal behavior, relationships (shared interests, etc)

Plus one of the following communication skill problems required Plus any two of the following required

Eye contact, language, initiate/sustain interactions, imaginative play Eye contact, language, initiate/sustain interactions, imaginative play(no language impairment required for Asperger's Disorder) Body language, understanding, tolerance for change, symbolic play(no cognitive impairment required for Asperger's Disorder) Ritualized patterns, focus on details

Plus one of the following repetitive behavior patterns Plus two of the following repetitive behavior patternsRoutines, stereotypic, restricted interests, sensory, preoccupations Routines, stereotypic, restricted interests, sensory, preoccupations

Plus Onset before age 3 Plus Onset in early childhood (not necessarily before age 3) or later

And impairment of social or language or symbolic/imaginative play And symptoms together limit and impair everyday functioning

Not Rett's Disorder or Childhood Disintegrative Disorder Not just General Developmental Delay


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The primary purpose of diagnosis is to classify and categorize a person to establish

a rationale and justification for treatment funding. A persons treatment plan is not

defined by their diagnosis. If it were, then only one treatment plan would be needed

to treat any person with autism. We all know the truism If youve met one person

with Autism, youve met one person with Autism. so it is obvious that diagnosis

has relatively little to do with responsible, ethical treatment planning.

The highlighted section is the DSM-IV TR standard for diagnosing autism which is

the current standard defined by the American Psychiatric Association in its

Diagnostic and Statistical Manual of Mental Disorders, version IV (Text Revision).

Note that many state Medicaid Plans explicitly reference the DSM-IV diagnostic

criteria so that they may require the use of DSM-IV criteria to establish the medical

necessity of a treatment plan under Medicaid, while the PRIVATE insurance

industry adopts the DSM-5 standard.


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The highlighted section is the proposed DSM-5 definition of autism spectrum

disorder which is expected be the standard as of May of 2013 for diagnosing

autism spectrum disorders according to the American Psychiatric Association in its

Diagnostic and Statistical Manual of Mental Disorders, version 5.


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The highlighted area summarizes the DSM-IV TR standards by identifying key

disability areas. Some people have referred to DSM-IV as a pick six standard

which seems to be more liberal than the all four required standard seemingly set

by DSM-5. Both of these perceptions of the DSM standard are oversimplified,

incorrect and misleading.

Circle the concepts in the highlighted section below the DSM-IV TR standard. You

can check to make sure that the highlighted concepts are actually contained in the

DSM-IV TR standard directly above.

Note that, under DSM-IV TR the childs condition must have had an onset before

age 3. DSM-5 sets no such limit on the age of the child; this is a significant

improvement.


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Now, circle the exact same words in the highlighted section below the DSM-5 standard. You cancheck to make sure that the circled concepts are actually contained in the DSM-5 standard directlyabove.

You will notice that all of the DSM-IV TR standards are incorporated into the DSM-5 standards andthat DSM-5 actually includes standards that were overlooked in DSM-IV. Thus, DSM-5 is actually a

better definition of Autism spectrum disorders than DSM-IV. It is also more aligned with the worldstandard of diagnostic classification (the International Classification of Diseases version 10 or ICD-10).

The biggest difference between DSM-IV TR and DSM-5 is that DSM-5 requires the condition to limitand impair every day functioning. Under DSM-IV TR, it is possible to diagnose high functioning

Autism (sometimes called Aspergers Disorder) that does not limit and impair every dayfunctioning. However, if a persons functioning is not limited or impaired, then the existence of aclinical syndrome or disabling condition is debatable the person may not be normal but if they arenot impaired, there is no need for a diagnosis because there is no need for funding to treat theircondition.

Note that the extent to which a condition serves to limit and impair every day functioning is a

continuum. It is not required that the condition severely impairs functioning, but some level oflimitation and impairment is obviously necessary in order to justify the diagnosis ofanydisorder.This is the Diagnostic and Statistical Manual of Mental Disorders, and is used to determine if fundingfor the treatment of mental disorders is appropriate. Autism Spectrum Disorders in DSM-5 are, justas in DSM-IV TR, mental disorders. If they were not, it could present grave consequences fortreatment funding through Medicaids EPSDT program and any number of recently passed state lawsmandating funding for the treatment of Autism Spectrum Disorders.

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