The New DSM 5 & Robert L. Hendren, DO, is currently a Autism - PowerPoint PPT Presentation

Faculty Disclosure The New DSM 5 & • Robert L. Hendren, DO, is currently a Autism member of Advisory Boards for BioMarin Pharmaceutical Inc., Forest Laboratories, and Janssen, and has received financial support for clinical trials in the past year from Autism Speaks Inc, BioMarin Pharmaceutical Inc., Curemark, Forest Laboratories, Vitamin D Council, and the National Institute of Mental Robert L. Hendren, D.O. Health. Professor & Vice Chair of Psychiatry Director, Child and Adolescent Psychiatry University of California, San Francisco DSM IV - Pervasive Autism Spectrum Disorders Developmental Disorders, Signs and Symptoms Autism Spectrum Disorders • Impaired social interaction − Lack of empathy, impaired nonverbal • Autistic disorder, high functioning autism communication, failure to develop relationships, lack of reciprocity • Asperger’s disorder • PDD NOS • Rett’s syndrome • Childhood Disintegrative Disorder PDD NOS, pervasive developmental disorder not otherwise specified American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed, text revision) . Washington, DC: 2000. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed, text revision) . Washington, DC: 2000.

Autism and Impaired Social Autism Spectrum Disorders Skills 1 Signs and Symptoms (cont’d) • Children with autism attach to their mothers 2 • Restricted, repetitive, stereotyped behaviors • Do not engage in attention-sharing behaviors 3 Excessive circumscribed preoccupations, inflexible, − motor mannerisms, preoccupation with parts of whole, • Do not recognize emotional expression, gesture difficulty with transitions and non-verbal vocalizations 1 • Language abnormalities • No significant language delay or cognitive • Do not know social (pragmatic) rules of interpersonal communication 1 delay in Asperger’s syndrome, not schizophrenia • Deficit in joint attention, theory of mind, affective reciprocity 3 1 Tanguay PE. J Psychiatry Neurosci . 1999;24:95-96; 2 Oppenheim D et al. Child Dev . American Psychiatric Association. Diagnostic and Statistical Manual of 2009;80:519-527; 3 Robertson JM et al. J Am Acad Child Adolesc Psychiatry . 1999;38:738-745. Mental Disorders (4th ed, text revision) . Washington, DC: 2000. � A. Autism Spectrum Disorder ASD DSM-5 Criteria (DSM-5) Meet criteria A, B, C, D & E including all 3 in A • New name for category which included autistic disorder, Asperger’s disorder, childhood A. Persistent deficits in social communication disintegrative disorder, and pervasive and social interaction across contexts: developmental disorder NOS • Social-emotional reciprocity (e.g. sharing interests, emotions, or affect; initiation; response) • Three domains become two: • Non-verbal communicative behaviors (e.g. eye 1. Social/communication deficits contact, body language, facial expression, gestures 2. Restricted, repetitive patterns of behavior, interests, or activities • Developing, maintaining & understanding relationships (e.g. adjusting behavior, imaginative play, making friends) • Several social/communication criteria were merged and streamlined to clarify diagnostic requirements American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed), APPI, Washington, DC

ASD DSM-5: Criteria (cont) ASD DSM-5: Criteria (cont) B. Restricted, repetitive patterns of behavior, C. Symptoms must be present in early childhood interests or activities; at least 2 of the following: (but may not become fully manifest until social demands exceed limited capacities; or masked • Stereotyped/repetitive speech, motor movements or use of objects by learned strategies) • Excessive adherence to routines/rituals or excessive resistance to change D. Symptoms cause clinically significant • Highly restricted fixated interest, abnormal in impairment intensity or focus • Hyper/hypo reactivity to sensory input or unusual interest in sensory aspects of the environment E. Not better explained by Intellectual Disability (ID) or Global Developmental Delay ASD DSM-5 Notes and ASD DSM-5: Severity Level Specifiers 3 levels of severity (not for service eligibility) • Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder • Level 1: Requiring Support (HFA) or PDD-NOS should be given the diagnosis of ASD – Difficulty initiating social interaction • Specify if – RRB’s cause significant interference – W or W/O intellectual impairment – W or W/O language impairment • Level 2: Requiring Substantial Support – Associated with known medical or genetic condition or – Marked deficits in verbal and nonverbal skills environmental factor (Rett’s, epilepsy, FAS) – Associated with another neurodevelopmental, mental or – RRB’s obvious to causal observer; distress behavioral disorder (ADHD, dev coordination d/o, disruptive behavior, impulse –control or CD, etc) • Level 3: Requiring Very Substantial Support – With catatonia (slowing, freezing) – Severe deficits in verbal and nonverbal skills – Preoccupations & RRB’s markedly interfere

ASD DSM-5: Other: ASD Differential DX (DSM-5) • Receptive and expressive language considered • Rett Syndrome separately • Selective Mutism • RRB’s were present during childhood but may not • Language Disorders and Social (pragmatic) be present in adulthood Communication Disorder • Best predictors of prognosis are the association of ID and/or language impairment • Intellectual Disability (ID) w/o ASD) • 15% associated with known genetic mutation • Stereotyped Movement Disorder • Attention-Deficit Hyperactivity Disorder (ADHD) • Schizophrenia Social (Pragmatic) ASD Comorbidity (DSM-5) Communication Disorder • 70% with ASD may have one comorbid disorder A. Persistent difficulties in pragmatic or social and 40% may have 2 or more uses of verbal & nonverbal communication • ID and structural language disorder - Deficits in using communication for social • ADHD purposes in appropriate manner • Developmental coordination disorder • Anxiety Disorders - Impairment in ability to change communication • Depressive Disorders to match context • Bipolar Disorder - Difficulties following rules for conversation and • Aggression – 53% - younger; assoc with medical comorbidities 1 storytelling (e.g. taking turns, rephrasing) • Sleep, feeding, GI issues - Difficulties understanding what is not explicitly stated and nonliteral or ambiguous meanings 1 Mazurek MO Research in ASD, 2013; 455-465 of language

Social (Pragmatic) Social (Pragmatic) Communication Disorder Communication Disorder • Result in functional limitations in effective B. Deficits result in functional limitations communication, social participation, social C. Onset is in early developmental period (but relationships, academic achievement, or deficits may not become manifest until occupational performance later) • ADHD, behavioral problems and LD more D. Symptoms not attributable to another medical common. or neurological condition or to low abilities • Outcome is variable in word structure or grammar or better • Fam Hx of ASD, communication disorders or explained by ASD, ID, GDD or another LD more common mental disorder. • DDX – ASD, ADHD, Social anxiety disorder, ID and GDD Global Developmental Language Delay DDx Delay • Autism Spectrum Disorder • Hearing loss • Children under age 5 when the clinical severity level cannot be reliably assessed. • Mental retardation • Fails to meet expected developmental • Expressive-receptive language disorder milestones in several areas. • Verbal Apraxia • Seizures (e.g. Landau-Kleffner Syndrome; acquired epileptic aphasia) • Neurodegenerative Disorder • Mitochondrial/metabolic Disorder