DSM-5 and Effect On Diagnosis and Intervention Dr Ranjini S. Sivanesom Consultant Developmental Paediatrician Institute of Paediatrics, Hospital

Transcription

1 DSM-5 and Effect On Diagnosis and Intervention Dr Ranjini S. Sivanesom Consultant Developmental Paediatrician Institute of Paediatrics, Hospital Kuala Lumpur

2 History and Autism 1943: First described by Kanner 1970: Autism was highly distinctive 1980: Autism officially recognized as a diagnosis in DSM-III 1994: DSM-IV 2000: DSM-IV TR, the diagnosis of autism required criteria in each of 3 domains: social relatedness, communication/ play and restricted interests and activities with onset by 3 years of age

3 Planning of DSM-5 began in Nine white papers Purpose: to stimulate research and discussion to improve the scientific basis of future classifications 2. Thirteen global research conferences ( ) Goal: to stimulate empirical research and promote international collaboration before formal development of DSM-5 3. DSM-5 Workgroups ( ) 4. DSM-5 (2013)

4 Goal of Revision for DSM-5 Enhance the reliability, validity and clinical utility of DSM (Diagnostic and Statistical Manual of Mental Disorders) for clinicians and researchers

5 Changes from DSM-IV-TR to DSM-5

6 New Disorders and Their Codes in DSM-5

7 DSM-IV-TR Disorders combined in DSM-5

8 Nomenclature Changes in DSM-5

9 Autism Spectrum Disorder (ASD) Autism spectrum disorder(asd) is a new DSM-5 disorder encompassing the previous DSM-IV autistic disorder (autism), Asperger's disorder, childhood disintegrative disorder, Rett's disorder and pervasive developmental disorder not otherwise specified. It is characterized by deficits in two core domains: 1. deficits in social communication and social interaction 2. restricted repetitive patterns of behavior, interests and activities

10 Autism Spectrum Disorder (ASD) (F84.0) Deficits in Social Communication and Social Interaction Restricted, repetitive patterns of Behavior, Interests and Activities Autism Spectrum Disorder

11 DSM-5 Criteria for ASD A. Persistent deficits in social communication and social interaction, as manifested by the following, currently or by history: 1. Deficits in social- emotional reciprocity 2. Deficits in nonverbal communicative behaviors used for social interaction 3. Deficits in developing, maintaining and understanding relationships

12 ASD Diagnostic Criteria B. Restricted, repetitive patterns of behavior, interests or activities as manifested by at least two of the following: 1. Stereotyped or repetitive motor movements, use of objects or speech 2. Insistence on sameness, inflexible adherence to routines or ritualized patterns of verbal or nonverbal behavior 3. Highly restricted, fixated interests that are abnormal in intensity or focus 4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment

13 ASD Diagnostic Criteria 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 or global developmental delay

14 Severity Levels for ASD Severity level Social communica0on Restricted, repe00ve behaviors Level 3 "Requiring very substan4al support" Severe deficits in social communica4on skills, very limited ini4a4on of social interac4ons and minimal response to social overtures from others. Inflexibility of behavior, extreme difficulty coping with change, or other restricted/ repe44ve behaviors markedly interfere with func4oning in all spheres. Great distress/ difficulty changing focus or ac4on Level 2 "Requiring substan4al support" Level 1 "Requiring support" Marked deficits in social communica4on skills, limited ini4a4on of social interac4ons and reduced or abnormal responses to social overtures from others Without supports in place, deficits in social communica4on cause no4ceable impairments. Difficulty ini4a4ng social interac4ons and atypical responses to social overtures of others Obvious interference with func4oning in a variety of contexts. Distress and/ or difficulty changing focus or ac4on Inflexibility of behavior causes significant interference with func4oning in one or more contexts. Difficulty switching between ac4vi4es.problems of organiza4on and planning hamper independence

15 Specifiers 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

16 Severity Specifiers for ASD Used to describe the current symptomatology Severity may vary by context and fluctuate over time. The descriptive severity categories should not be used to determine eligibility for provision of services

17 Important New Changes in DSM-5 ASD criteria in DSM-5 address concerns about diagnostic conversion and diagnostic independence 1. Inclusion of 'by history' in the assessment of diagnostic criteria 2. Individuals with established diagnosis of PDD (Pervasive Developmental Disorder) should be given the diagnosis of ASD 3. Elimination of 'trumping rules' that had previously prevented the co-diagnosis of attention deficit disorder or of schizophrenia in the setting of autism

18 DSM-5 Validation Frazier et al,jaacap,jan 2012;51(1): ,744 siblings (8911 ASD, 5863 non-asd) from the Interactive Autism Network (national registry) Hybrid model of categorical and dimensional criteria supported DSM- IV TR DSM- 5 Sensi4vity Specificity At risk for false negative Females Asperger's disorder

19 Sensitivity and Specificity of DSM-5 Criteria McPartland et al. JAACAP,2012;51(4) patients evaluated from DSM-IV field trial exposed to DSM-5 criteria Overall 60.6% of cases with ASD met revised DSM-5 diagnostic criteria Overall specificty was 94.9% Diagnosis Au4sm 0.76 Asperger's disorder 0.25 PDD- NOS 0.28 IQ< IQ Sensi0vity

20 Most children with DSM-IV PDD (pervasive developmental disorder) remain eligible for an ASD diagnosis under the DSM-5 criteria

21 Diagnosis Considerable variability is present in making diagnosis in different contexts --< makes it difficult to interpret trends in prevalence and compare studies Developed nation,use different methods and criteria The early detection and provision of services improve long- term prognosis makes early diagnosis important

22 Diagnosis Clinicians should be sensitive to ethnic, cultural or socioeconomic factors that may affect assessment Psychological assessment (cognitive ability and adaptive skills) is indicated for treatment planning and helps to frame observed socialcommunication difficulties relative to overall development Psychological test clarify areas of strength and weakness useful in designing intervention programme

23 Intervention Individuals with an ASD can present for clinical care at any point in development Multidisciplinary care, coordination of sevices and advocacy for individuals and their families Early sustained intervention and the use of multiple treatment modalities are indicated It will be some years before the implications of DSM-5 criteria for other facets of assessment and intervention can be fully assessed

24 Intervention DSM-5 will affect several dimensions: - access to services - education - broader policy Treatment - medical - education

25 Treatment ADHD (attention deficit hyperactive disorder) can be diagnosed along with ASD Pharmaceutical (stimulant) + behavioral intervention Positive outcome with stimulant: improvement in executive functioning and reduction in stereotypy, aggressive behaviors and irritability ASD and ADHD: parent training to improve emotional regulation and medication to improve attention, before receiving social skill training (to promote peer relations) Frazier TW, et al. J Child Adolesc Psychopharmacol. 2011;21(6):571 9

26 Education (Malaysia) Educational eligibilities are determined using medical diagnosis Mainstream Special education NGO Home schooling

27 Autism Data (Health Informatics Centre, Planning and Development Division, Ministry of Health Malaysia) Year (Age) Peninsula Malaysia East Malaysia 2004 (0-12 yrs) (0-12 yrs) (0-12 yrs) (0-12 yrs) (0-12 yrs) (0-12 yrs) (0-12 yrs) (0-12 yrs) (0-12 yrs) (0-18 yrs) Malaysia (Total)

28 Screening and Assessment (Malaysia) Screening (M-CHAT) Family Medicine Specialist Paediatrician (334 Ministry of Health, 422 university & private hospital) Child Psychiatrist Developmental paediatrician (5)

29 'Kids don't read the DSM' Dennis Cantwell, DSM-III task force

30 Summary DSM-5 introduces a controversial shift away from discrete and independent categorical entities within the pervasive developmental disorders spectrum to a single construct of ASD Specificity improved but excluded a substantial portion of cognitively able individuals and those with ASDs other than autistic disorder DSM-5 criteria holds significant public health outcome regarding service eligibility and compatability of historical and future research

31 Summary DSM-5 criteria will provide a more specific framework to guide diagnosis, prevalence, treatment and research while continuing to acknowledge the heterogeneity of this disorder DSM-5 should be welcomed

32 The Future The effect of DSM-5 diagnostic criteria on diagnosis and intervention can be determined when this criteria is consistently applied and research conducted

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34 Thank You