DSM-5's conceptualization of autistic disorders

Clinical presentations of social communication disorder: A case series

Social Communication Disorder (SCD) is a new DSM-5 diagnostic category poorly understood by clinicians. We describe a case series of four individuals diagnosed with SCD to identify common characteristics and differences in presentations of the disorder. All cases had deficits in the area of social communication, and sub-threshold level of restricted and repetitive behaviours, not sufficient to meet criteria for Autism Spectrum Disorder (ASD). All cases presented with at least one mental health co-morbid condition. There are significant overlaps in clinical presentation between SCD and ASD. It is imperative that accurate diagnostic tools and effective intervention approaches of SCD be developed.

Applying Item Response Theory Modeling to Identify Social (Pragmatic) Communication Disorder

Purpose No diagnostic tools exist for identifying social (pragmatic) communication disorder (SPCD), a new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition category for individuals with social communication deficits but not the repetitive, restricted behaviors and interests (RRBIs) that would qualify them for a diagnosis of autism spectrum disorder (ASD). We explored the value of items from a widely used screening measure of ASD for distinguishing SPCD from typical controls (TC; Aim 1) and from ASD (Aim 2). Method We applied item response theory (IRT) modeling to Social Communication Questionnaire-Lifetime (Rutter, Bailey, & Lord, 2003) records available in the National Database for Autism Research. We defined records from putative SPCD (n = 54), ASD (n = 278), and TC (n = 274) groups retrospectively, based on National Database for Autism Research classifications and Autism Diagnostic Interview-Revised responses. After assessing model assumptions, estimating model parameters, and measuring model fit, we identified items in the social communication and RRBI domains that were maximally informative in differentiating the groups. Results IRT modeling identified a set of seven social communication items that distinguished SPCD from TC with sensitivity and specificity > 80%. A set of five RRBI items was less successful in distinguishing SPCD from ASD (sensitivity and specificity < 70%). Conclusion The IRT modeling approach and the Social Communication Questionnaire-Lifetime item sets it identified may be useful in efforts to construct screening and diagnostic measures for SPCD.

"In Medical School, You Get Far More Training on Medical Stuff than Developmental Stuff": Perspectives on ASD from Ontario Physicians

This study investigated the knowledge and perceived competence of Ontario physicians regarding the diagnosis and treatment of ASDs. Previous research demonstrates that many physicians would like more education regarding diagnosis and treatment of autism spectrum disorders (ASDs). Twenty-seven Ontario physicians filled out a questionnaire and participated in a semi-structured interview. Findings revealed that despite participants' high perceived knowledge regarding diagnosis and treatment of ASDs, they feel uncomfortable in providing care for this population. Furthermore, many participants stated diagnosing and treating ASDs is not within their scope of practice. Findings have implications for increasing physicians' knowledge of diagnosis and treatment of ASDs as well as what is required to enhance healthcare for individuals with ASDs and their families.

Measuring the Diagnostic Features of Social (Pragmatic) Communication Disorder: An Exploratory Study

PURPOSE

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition introduced a new neurodevelopmental disorder, social (pragmatic) communication disorder (SPCD), that is characterized by deficits in 4 areas of communication. Although descriptions of these areas are provided, no assessment tools for SPCD are recommended. The purpose of this study was to examine the extent to which items from measurement tools commonly used in assessing pragmatic language impairment and related disorders might be useful in assessing the characteristics of social communication that define SPCD in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

METHOD

Based on a literature search, 594 items from assessment tools commonly used to measure social communication abilities in people with pragmatic language impairment were identified. The first author judged whether each item reflected 1, more than 1, or none of the 4 SPCD diagnostic characteristics. After a brief training process, 5 second raters independently mapped subsets of items to the 6 categories. We calculated the percentage of agreement and Cohen's kappa for each pair of raters in assigning items to categories.

RESULTS

Percentages of agreement ranged from 76% to 82%, and Cohen's kappa values ranged from .69 to .76, indicating substantial agreement. Sources and item numbers for the 206 items that both raters assigned to the same SPCD feature are provided.

CONCLUSIONS

These items may provide guidance in assessing SPCD and in designing standardized screening and diagnostic measures for SPCD.

Social (pragmatic) communication disorders and autism spectrum disorder

Changes have been made to the diagnostic criteria for autism spectrum disorder (ASD) in the recent revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and similar changes are likely in the WHO International Classification of Diseases (ICD-11) due in 2017. In light of these changes, a new clinical disorder, social (pragmatic) communication disorder (SPCD), was added to the neurodevelopmental disorders section of DSM-5. This article describes the key features of ASD, SPCD and the draft ICD-11 approach to pragmatic language impairment, highlighting points of overlap between the disorders and criteria for differential diagnosis.

Concerns about identity and services among people with autism and Asperger's regarding DSM-5 changes

The Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-5]; American Psychiatric Association, 2012 ) now includes a new autism spectrum diagnosis (ASD) with previous separate diagnoses of autism removed. This study explores the concerns of people with Asperger's syndrome (AS) and autistic disorder (AD). Discussion forum data of people with AS and AD (N = 76) were analyzed using phenomenological, inductive-content analysis to gather qualitative data about the concerns of people with AS and AD regarding the changes in the DSM-5. People with AS and AD were concerned about identity, community, the cure movement, and services. They also discussed using advocacy and solidarity to address their concerns.

Formal thought disorder in autism spectrum disorder predicts future symptom severity, but not psychosis prodrome

Formal thought disorder (FTD) is a disruption in the flow of thought, which is inferred from disorganisation of spoken language. FTD in autism spectrum disorders (ASD) might be a precursor of psychotic disorders or a manifestation of ASD symptom severity. The current longitudinal study is a seven-year follow-up of 91 individuals aged 5-12 years with ASD. We tested (1) whether childhood FTD predicted prodromal symptoms of psychosis in adolescence and (2) whether childhood FTD was associated with greater ASD symptom severity in adolescence. ASD symptom severity was assessed in childhood (T1) and 7 years later (T2), using the autism diagnostic observation schedule (ADOS). At T1, the Kiddie-Formal Thought Disorder Rating Scale (KFTDS) was used to measure symptoms of FTD. At T2, the prodromal questionnaire (PQ) was used to assess prodromal symptoms of psychosis. FTD at T1 did not predict prodromal symptoms of psychosis at T2 in children with ASD. FTD symptoms at T1, namely illogical thinking, predicted ASD symptom severity at T2 and this effect remained significant after controlling for T1 ASD symptom severity. In children with ASD, illogical thinking predicts severity of ASD symptoms in adolescence, but FTD does not predict prodromal symptoms of psychosis.

Genetic risk for attention-deficit/hyperactivity disorder contributes to neurodevelopmental traits in the general population

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) can be viewed as the extreme end of traits in the general population. Epidemiological and twin studies suggest that ADHD frequently co-occurs with and shares genetic susceptibility with autism spectrum disorder (ASD) and ASD-related traits. The aims of this study were to determine whether a composite of common molecular genetic variants, previously found to be associated with clinically diagnosed ADHD, predicts ADHD and ASD-related traits in the general population.

METHODS

Polygenic risk scores were calculated in the Avon Longitudinal Study of Parents and Children (ALSPAC) population sample (N = 8229) based on a discovery case-control genome-wide association study of childhood ADHD. Regression analyses were used to assess whether polygenic scores predicted ADHD traits and ASD-related measures (pragmatic language abilities and social cognition) in the ALSPAC sample. Polygenic scores were also compared in boys and girls endorsing any (rating ≥ 1) ADHD item (n = 3623).

RESULTS

Polygenic risk for ADHD showed a positive association with ADHD traits (hyperactive-impulsive, p = .0039; inattentive, p = .037). Polygenic risk for ADHD was also negatively associated with pragmatic language abilities (p = .037) but not with social cognition (p = .43). In children with a rating ≥ 1 for ADHD traits, girls had a higher polygenic score than boys (p = .003).

CONCLUSIONS

These findings provide molecular genetic evidence that risk alleles for the categorical disorder of ADHD influence hyperactive-impulsive and attentional traits in the general population. The results further suggest that common genetic variation that contributes to ADHD diagnosis may also influence ASD-related traits, which at their extreme are a characteristic feature of ASD.

Practitioner review: Social (pragmatic) communication disorder conceptualization, evidence and clinical implications

BACKGROUND

DSM-5 sees the introduction of Social (Pragmatic) Communication Disorder (SPCD), characterized by persistent difficulties using verbal and nonverbal communication for social purposes, in the absence of restricted and repetitive interests and behaviours. There is currently much confusion about the precise diagnostic criteria for SPCD and how this disorder relates to autism spectrum disorders (ASD), previous descriptions of pragmatic language impairment (PLI) and more specific language disorders (LD).

METHOD

Proposed criteria for SPCD are outlined. A selective review of the evidence considers whether these criteria form a cohesive and distinct diagnostic entity. Approaches to assessment and intervention are discussed.

RESULTS

Implementing the new diagnosis is currently challenged by a lack of well-validated and reliable assessment measures, and observed continuities between SPCD and other neurodevelopmental disorders. High rates of comorbidity between SPCD and other seemingly disparate disorders (including conduct disorder, ADHD and disorders of known genetic origin) raise questions about the utility of this diagnostic category.

CONCLUSIONS

SPCD is probably best conceptualized as a dimensional symptom profile that may be present across a range of neurodevelopmental disorders, although there is an urgent need to investigate the latent structure of SPCD using consistent diagnostic criteria. In addition, social communication and aspects of pragmatic language may be dissociated, with the latter heavily influenced by structural language attainments. Finally, there is a dearth of reliable and culturally valid assessment measures with which to make a differential diagnosis, and few rigorously tested intervention programmes. The implications for research and clinical practice are outlined.

Comparisons between autism spectrum disorders and anxiety disorders: findings from a clinic sample in Singapore

INTRODUCTION

The goals of the present study were to: (i) examine similarities and differences in behavioral/emotional problems manifested by children with autism spectrum disorder (ASD) and those with anxiety disorder (ANX); (ii) test the ability of each of the eight child behavioral checklist (CBCL) and teacher report form (TRF) syndrome scales to differentiate the ASD group from the ANX group; and (iii) test the ability of an ASD scale derived by Ooi et al. to differentiate the ASD group from the ANX group.

METHODS

Archival CBCL and TRF data from 180 children between 4 and 18 years of age (119 males, 61 females) diagnosed with ASD (n = 86) or ANX (n = 94) at an outpatient child psychiatric clinic in Singapore were analyzed.

RESULTS

The ASD group scored significantly higher on Social Problems and Attention Problems but significantly lower on Anxious/Depressed and Somatic Complaints than the ANX group. The groups did not show significant differences on Withdrawn/Depressed and Thought Problems. Both the CBCL and TRF ASD scales were significant predictors of the ASD group, with moderate to high sensitivity and specificity.

DISCUSSION

Our findings for an Asian sample support the diagnostic overlap between ASD and ANX reported for Western samples and underscore the importance of treating ASD as both a unitary disease and as a web of overlapping configurations of underlying problem dimensions.

Empirically based phenotypic profiles of children with pervasive developmental disorders: interpretation in the light of the DSM-5

This study aimed to contribute to the Diagnostic and Statistical Manual (DSM) debates on the conceptualization of autism by investigating (1) whether empirically based distinct phenotypic profiles could be distinguished within a sample of mainly cognitively able children with pervasive developmental disorder (PDD), and (2) how profiles related to diagnoses and co-occurring behavioral and emotional problems. Six classes with distinct profiles were discerned. Three classes showed profiles not completely in line with the proposed DSM-5 conceptualization of autism. These classes included relatively many cognitively able individuals with PDD-not otherwise specified. However, profiles seemed to suit other diagnostic categories, such as social communication disorder. These alternative diagnoses could retain eligibility for services, and might adequately fit more specifically targeted interventions.

ASSERT--the Autism Symptom SElf-ReporT for adolescents and adults: bifactor analysis and validation in a large adolescent population

With a view to developing a brief screening instrument for autism symptoms in a general population of adolescents, seven items from the Asperger syndrome (and high-functioning autism) diagnostic interview were adapted for use as self-report in an online questionnaire for youths aged 16-19 years (N=10,220). The selected items target lack of social understanding (4 items) and rigid and repetitive behavior and interests (RRBI; 3 items). Factor analyses were performed, and the seven items were also validated against self-reported ASD diagnosis. Best statistical model fit was found for a bifactor model with one general factor and two domain specific factors tied to social difficulties and RRBI. Both the general and the domain specific factors were associated with self-reported ASD diagnoses. The scale (referred to as the Autism Symptom SElf-ReporT for Adolescents and Adults--ASSERT) had good screening properties with a receiver operating curve-area under the curve (ROC-AUC) of 0.87 and a diagnostic odds ratio (DOR) of 15.8. Applying a modified scoring of the scale further improved the screening properties leading to a ROC-AUC of 0.89 and a DOR of 24.9. The ASSERT holds promise as a brief self-report screen for autism symptoms in adolescents, and further studies should explore its usefulness for adults.

Current progress and challenges in the search for autism biomarkers

Autism spectrum disorders (ASD) encompass a range of neurodevelopmental conditions that are clinically and etiologically very heterogeneous. ASD is currently diagnosed entirely on behavioral criteria, but intensive research efforts are focused on identifying biological markers for disease risk and early diagnosis. Here, we discuss recent progress toward identifying biological markers for ASD and highlight specific challenges as well as ethical aspects of translating ASD biomarker research into the clinic.

Autism susceptibility genes and the transcriptional landscape of the human brain

Autism is the most severe end of a spectrum of neurodevelopmental conditions, autism spectrum disorders (ASD). ASD are genetically heterogeneous, and hundreds of genes have been implicated in the etiology of the disease. Here, we discuss the contribution of brain transcriptome studies in advancing our understanding of the genetic mechanisms of ASD and review recent work characterizing the spatial and temporal variation of the human brain transcriptome, with a focus on the relevance of these data to autism susceptibility genes.