September Breakfast

On Sept. 5, 2014, Judith Miller,Ph.D. of the Center for Autism Research at Children’s Hospitalof Philadelphia, presented on “DSM-5: Changes to Autism Spectrum Disorder and Intellectual Disabilities” This topic drew a large and interested audience because of ongoing changes in the use of the new criteria for these diagnoses, and their implications for services children may receive.

Dr.Miller noted the history of changes in DSM descriptions and criteria for autism and similar disorders. From 1980 on, there have been alterations in DSM views of autistic disorders and pervasive developmental disorders, with the addition of Rett’s disorder, childhood disintegrative disorder, and Asperger’s disorder in 2000. DSM-5 omits some of these categories and places individuals on an autism spectrum disorder continuum, with narrative descriptions of specific criterion skills and behaviors, and assessment of the severity of each problem in terms of services needed.

Comparing the DSM-IV-Tr criteria for autism to the DSM-5 criteria for ASD, Dr. Miller pointed out that the delayed language criterion, at one time such a focus for assessment of autism, has now been removed from the DSM-5 list. The reason for this was that this problem is not unique to autism, and in fact with increased access to speech interventions is less likely than it once was. Language problems are still of interest in the DSM-5 approach, but are considered as aspects of social-emotional reciprocity and of stereotyping.

Like DSM-IV-Tr, DSM-5 looks at a category of nonverbal communication. There is a concern with difficulties with relationships in general, not just with the peer relationships of concern to DSM-IV-Tr; the old criterion of delayed pretend play is also included in the relationship category.  The old categories of lack of emotional reciprocity and impaired conversations are included as aspects of  social-emotional reciprocity.  Circumscribed interests continue to be a criterion, as do routines and resistance to change. Stereotyped movements, speech, and object use  now takes the place of stereotyped language and stereotyped movements. The earlier “preoccupation with parts” criterion is now expanded to unusual sensory reactivity or interest, although Dr.Miller pointed out that not all ASD children have these and that the evidence for Sensory Integration Disorder is weak. Finally, the old criterion of onset before 30 months is now broadened to onset in early developmental period. Each of these criteria is considered in terms of its severity and the level of support the child needs.

The narrative description required by DSM-5, which no longer uses the “axis” approach, is intended to focus on a child’s individual pattern of strengths and weaknesses and to avoid the “diagnostic overshadowing” that suggests that all children with a diagnosis are alike. Children who have deficits in social communication but do not meet other criteria for ASD should be evaluated for social communication disorder. Dr. Miller also stressed the fact that autism is simultaneously heterogeneous and often coupled with co-occurring diagnoses.

Problems that have known medical or genetic foundations, like Rett’s disorder or Fragile X, are no longer included in this diagnostic category. However, children who were previously diagnosed as autistic under DSM-IV-Tr will be “grandfathered” into the new diagnostic category with respect to the availability of services.

Audience questions included a number of inquiries about how these changes affect the services children get. Dr. Miller noted that the States interpret Federal criteria in different ways, but that school districts also develop their own cultures that help to determine how services are provided. One audience member referred to her experience that parents are quick to accept the idea that a child is autistic without waiting for a full assessment. This question led to a discussion of which professionals can diagnose ASD, with the conclusion that although people should be working within the scope of their expertise, state laws differ with respect to the role of social workers in ASD diagnosis.

The interest of the audience in ASD limited the time that Dr. Miller was able to give to the new DSM-5 diagnosis of Intellectual Disability Disorder, now replacing the term “mental retardation”. However, she noted the DSM-5 emphasis on adaptive impairments in various areas, and pointed out that IQ scores are more problematic at the low end of the range.