DSM-IV vs DSM-5 diagnostic criteria for toddlers with autism

Impact of Preterm Birth on Neurodevelopmental Disorders in South Korea: A Nationwide Population-Based Study

Neurodevelopmental disorder (NDD) in preterm infants has become of great interest. We aimed to investigate the impact of preterm birth on the proportion of NDD using nationwide data provided by the Korean National Health Insurance Service. We included 4894 extremely preterm or extremely low-birth-weight (EP/ELBW; <28 weeks of gestation or birth weight < 1000 g) infants, 70,583 other preterm or low-birth-weight (OP/LBW; 28−36 weeks of gestation or birth weight < 2500 g) infants, and 264,057 full-term infants born between 2008 and 2015. We observed their neurodevelopment until 6 years of age or until the year 2019, whichever occurred first. Diagnoses of NDDs were based on the World Health Organization’s International Classification of Diseases 10th revision. An association between preterm birth and NDD was assessed using a multivariable logistic regression model. There was a stepwise increase in the risk of overall NDD with increasing degree of prematurity, from OP/LBW (adjusted odds ratio 4.46; 95% confidence interval 4.34−4.58), to EP/ELBW (16.15; 15.21−17.15). The EP/ELBW group was strongly associated with developmental delay (21.47; 20.05−22.99), cerebral palsy (88.11; 79.89−97.19), and autism spectrum disorder (11.64; 10.37−13.06). Preterm birth considerably increased the risk of NDD by the degree of prematurity.

The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond

In this paper we review the impact of DSM-III and its successors on the field of autism-both in terms of clinical work and research. We summarize the events leading up to the inclusion of autism as a "new" official diagnostic category in DSM-III, the subsequent revisions of the DSM, and the impact of the official recognition of autism on research. We discuss the uses of categorical vs. dimensional approaches and the continuing tensions around broad vs. narrow views of autism. We also note some areas of current controversy and directions for the future.

DSM-5 symptom expression in toddlers

LAY ABSTRACT

Children with autism show more social-communication symptoms and repetitive behaviors than children with typical development or those diagnosed with other developmental disorders; however, non-autistic children often show some behaviors that are associated with autism. We compared the behavioral reports from caregivers of children in these three groups to identify the behaviors that were specific to autism. Children with autism were found to show more of these behaviors, and behaviors that are particularly indicative of autism were identified. These behaviors included social symptoms (approaching others to interact, showing things, looking back while showing, responding to an approaching child, spontaneous imitation) and repetitive behavior symptoms (specific, inflexible play, unusual body movements, strong specific interest, carrying around an unusual object, sensory seeking, and sensory hyper-reactivity).These findings may aid professionals in determining the most appropriate diagnosis for a child between the ages of 12 and 36 months.

Seeing the forest and the trees: Disentangling autism phenotypes in the age of DSM-5

This paper, written in honor of Professor Ed Zigler, focuses on some of the themes in developmental disabilities research that were so central to his work. It has now been nearly 80 years since Leo Kanner first identified the prototypic form - early infantile autism - of what is now autism spectrum disorder. In this article we summarize the development of the concept and the important accumulation of knowledge over time that has now led us to the recognition of a broader autism phenotype just as, at the same time, the current official diagnostic system in the USA has narrowed the concept. We also address current controversies regarding autism as the diagnosis is impacted by age and developmental factors, gender, and cultural issues. In parallel to the work on intellectual deficiency and development pioneered by Zigler and his colleagues, we summarize some of the challenges for the years ahead.

Age-Specific Time Trends in Incidence Rates of Autism Spectrum Disorder Following Adaptation of DSM-5 and Other ASD-Related Regulatory Changes in Israel

We analyzed data on 879,029 children born in 1999-2017 from a large Israeli health fund to evaluate time-trends in incidence of autism spectrum disorder (ASD). This included examining possible effects associated with the adaptation of the DSM-5 criteria for ASD, and the implementation of regulatory changes affecting eligibility for ASD-related stipends and services. ASD cases were ascertained based on electronic medical records review, with complete verification of ASD case status. Results indicated a substantial increase in ASD incidence rate (IR) over time that was overall not appreciably affected by the above changes. Cumulative incidence through age 8 rose from 0.46% (boys: 0.73; girls: 0.18) in 2007 to 1.30% (boys: 2.12; girls: 0.45) in 2018. Age-specific analyzes indicated that the largest increase in IR occurred in toddlers and preschool children, with a more modest increase at older age groups. Results suggest that the rise in early diagnosed ASD does not stem from a downward shift in the distribution of ages at first diagnosis, but rather from early detection of cases not previously diagnosed. Findings highlight the need to expand research aimed at identifying exogenous factors that may underlie the rise in incidence, and to evaluate factors that may contribute to late diagnosis of some cases. Autism Res 2020, 13: 1893-1901. © 2020 International Society for Autism Research and Wiley Periodicals LLC LAY SUMMARY: In an analysis of nearly 900,000 Israeli children born in 1999-2017, we found that the incidence of autism spectrum disorder (ASD) increased significantly over time, especially among toddlers and preschool children but also at older age groups. We additionally observed that changes affecting diagnostic criteria for ASD and eligibility for ASD-related services did not appreciably affect these trends. Results highlight the need to continue research aimed at identifying factors causing this increase and reasons contributing to late diagnosis of some cases.

How has DSM-5 Affected Autism Diagnosis? A 5-Year Follow-Up Systematic Literature Review and Meta-analysis

We conducted a 5-year follow-up systematic review and meta-analysis to determine change in frequency of autism spectrum disorder (ASD) diagnosis since diagnostic and statistical manual 5 (DSM-5) publication and explore the impact of Social Communication Disorder (SCD). For 33 included studies, use of DSM-5 criteria suggests decreases in diagnosis for ASD [20.8% (16.0-26.7), p < 0.001], DSM-IV-TR Autistic Disorder [10.1% (6.2-16.0), p < 0.001], and Asperger's [23.3% (12.9-38.5), p = 0.001]; pervasive developmental disorder-not otherwise specified decrease was not significant [46.1% (34.6-58.0), p = 0.52]. Less than one-third [28.8% (13.9-50.5), p = 0.06] of individuals diagnosed with DSM-IV-TR but not DSM-5 ASD would qualify for SCD. Findings suggest smaller decreases in ASD diagnoses compared to earlier reviews. Future research is needed as concerns remain for impaired individuals without a diagnosis.

Disparities in Documented Diagnoses of Autism Spectrum Disorder Based on Demographic, Individual, and Service Factors

The objectives of our study were to (a) report how many children met an autism spectrum disorder (ASD) surveillance definition but had no clinical diagnosis of ASD in health or education records and (b) evaluate differences in demographic, individual, and service factors between children with and without a documented ASD diagnosis. ASD surveillance was conducted in selected areas of Arizona, Arkansas, Colorado, Georgia, Maryland, Minnesota, Missouri, New Jersey, North Carolina, Tennessee, and Wisconsin. Children were defined as having ASD if sufficient social and behavioral deficits and/or an ASD diagnosis were noted in health and/or education records. Among 4,498 children, 1,135 (25%) had ASD indicators without having an ASD diagnosis. Of those 1,135 children without a documented ASD diagnosis, 628 (55%) were not known to receive ASD services in public school. Factors associated with not having a clinical diagnosis of ASD were non-White race, no intellectual disability, older age at first developmental concern, older age at first developmental evaluation, special education eligibility other than ASD, and need for fewer supports. These results highlight the importance of reducing disparities in the diagnosis of children with ASD characteristics so that appropriate interventions can be promoted across communities. Autism Res 2020, 13: 464-473. © 2019 International Society for AutismResearch,Wiley Periodicals, Inc. LAY SUMMARY: Children who did not have a clinical diagnosis of autism spectrum disorder (ASD) documented in health or education records were more likely to be non-White and have fewer developmental problems than children with a clinical diagnosis of ASD. They were brought to the attention of healthcare providers at older ages and needed fewer supports than children with a clinical diagnosis of ASD. All children with ASD symptoms who meet diagnostic criteria should be given a clinical diagnosis so they can receive treatment specific to their needs.

Autism spectrum disorder

Sources of data

This article is based on key recent published literature including international guidelines and relevant reviews and meta-analyses. Authors have also supplemented this material with their own clinical experience.

Areas of agreement

There is an agreement that autism spectrum disorder (ASD) have a strong hereditary component. There is also a consensus that the reported prevalence estimates have increased in the last 5 years. There is strong support for using the broader spectrum disorder conceptualization of the DSM-5.

Areas of controversy

Higher public awareness of ASD has generated several controversial theories of causation. We review a number of environmental risk factors receiving media attention including: vaccines, mercury, heavy metal exposure and Selective Serotonin Uptake Inhibitors (SSRIs). Popular yet controversial treatment interventions are discussed. Early diagnostic screening tools are also addressed.

Growing points

There is increasing scientific interest in identifying biomarkers of autism with potential for early diagnosis, prognostic indicators and predictive treatment responses. We review evidence from genetics, neuroimaging and eye tracking as candidate biomarkers.

Area timely for developing research

Family studies point to a strong hereditary component in the aetiology of autism. However these studies have not established 100% concordance rates, suggesting a role for environmental factors. The gene-environment interplay has not received enough attention in scientific research. This represents an important new avenue for research in ASD.

Comparison of autism spectrum disorder surveillance status based on two different diagnostic schemes: Findings from the Metropolitan Atlanta Developmental Disabilities Surveillance Program, 2012

For the first time, the Autism and Developmental Disabilities Monitoring Network (ADDM) at the Centers for Disease Control and Prevention (CDC) reported prevalence estimates based on two different diagnostic schemes in the 2014 surveillance period. Results found substantial agreement between surveillance case status based on Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision (DSM-IV-TR) criteria and DSM-5 criteria ASD (kappa = 0.85). No study has replicated this agreement in another independent sample of surveillance records. The objectives of this study were to (1) replicate agreement between surveillance status based on DSM-IV-TR criteria and DSM-5 criteria for ASD, (2) quantify the number of children who met surveillance status based on only DSM-IV-TR criteria and only DSM-5 criteria for ASD, and (3) evaluate differences in characteristics of these latter two groups of children. The study sample was 8-year-old children who had health and education records reviewed for ASD surveillance in metropolitan Atlanta, GA in the 2012 surveillance year. Results found substantial agreement between child's surveillance status using DSM-IV-TR criteria and DSM-5 criteria for ASD (kappa = 0.80). There were no differences in child race/ethnicity, child sex, or intellectual disability between surveillance status defined by DSM-IV-TR criteria and that defined by DSM-5 criteria. Children who met surveillance status based on DSM-IV-TR criteria, but not DSM-5 criteria, were more likely to have developmental concerns and evaluations in the first three years. Children who met surveillance status based on DSM-5 criteria, but not DSM-IV-TR criteria, were more likely to have been receiving autism-related services or previously diagnosed with ASD. These results suggest that surveillance status of ASD based on DSM-5 criteria is largely comparable to that based on DSM-IV-TR criteria, and identifies children with similar demographic and intellectual characteristics.

A Prospective Study of the Concordance of DSM-IV and DSM-5 Diagnostic Criteria for Autism Spectrum Disorder

The transition from DSM-IV to DSM-5 criteria for autism spectrum disorder (ASD) sparked considerable concern about the potential implications of these changes. This study was designed to address limitations of prior studies by prospectively examining the concordance of DSM-IV and final DSM-5 criteria on a consecutive sample of 439 children referred for autism diagnostic evaluations. Concordance and discordance were assessed using a consistent diagnostic battery. DSM-5 criteria demonstrated excellent overall specificity and good sensitivity relative to DSM-IV criteria. Sensitivity and specificity were strongest for children meeting DSM-IV criteria for autistic disorder, but poor for those meeting criteria for Asperger's disorder and pervasive developmental disorder. Higher IQ, older age, female sex, and less pronounced ASD symptoms were associated with greater discordance.

A Comparison of DSM-IV-TR and DSM-5 Diagnostic Classifications in the Clinical Diagnosis of Autistic Spectrum Disorder

Aim of this study was to compare children diagnosed with Pervasive Developmental Disorder (PDD) according to DSM-IV-TR and DSM-5 diagnostic systems. One hundred fifty children aged between 3 and 15 years diagnosed with PDD by DSM-IV-TR were included. PDD symptoms were reviewed through psychiatric assessment based on DSM-IV-TR and DSM-5 criteria. Clinical severity was determined using Childhood Autism Rating Scale (CARS) and Autism Behavior Checklist (ABC). A statistically significant decrease (19.3 %) was detected in the diagnostic ratio with DSM-5. Age and symptom severity differed significantly between those who were and were not diagnosed with PDD using DSM-5. B4 criteria in DSM-5 was most common criterion. Results indicate that individuals diagnosed with PDD by DSM-IV-TR criteria may not be diagnosed using DSM-5 criteria.

An evaluation of the clinical application of the DSM-5 for the diagnosis of autism spectrum disorder

INTRODUCTION

The changes to the diagnostic criteria for autism spectrum disorder (ASD) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) were met with much controversy by researchers, clinicians, and families of individuals with ASD. The goal of this paper is to review the literature on the impact of these changes. Areas covered: This paper reviews the major changes to diagnostic criteria from DSM-IV-TR to DSM-5. It emphasizes how these changes are hypothesized to impact prevalence rates, as well as trends in characteristics of individuals who would have met previous criteria for ASD but no longer qualify for a diagnosis under DSM-5. Policy issues such as access to services and research considerations are also briefly reviewed. Expert commentary: Researchers have found that the DSM-5 diagnostic criteria for ASD may significantly impact which children receive diagnoses, which in turn affects access to services that address impairments characteristic of this disorder. Despite the fact that the DSM-5 has now been in use for four years, fewer recent studies were identified than was expected. Future research should continue to focus on the impact of changes in criteria, as well as on translational scientific advances across disciplines.

Autism Spectrum Disorder in the DSM-5: Diagnostic Sensitivity and Specificity in Early Childhood

Changes to the DSM-5 Autism Spectrum Disorder (ASD) criteria raised concerns among parents and practitioners that the criteria may exclude some children with Pervasive Developmental Disorder (PDD). Few studies have examined DSM-5 sensitivity and specificity in children less than 5 years of age. This study evaluated 185 children aged 20-55 months with DSM-IV PDD or developmental delay. Autism Diagnostic Interview-Revised (ADI-R) and Autism Diagnostic Observation Schedule (ADOS) data was assigned to DSM-5 subdomains. Children displaying the required symptomatology were classified with DSM-5 ASD. DSM-IV clinical diagnoses were compared to DSM-5 classifications. Using combined ADI-R/ADOS information, sensitivity was .84 and specificity was .54. Comorbid behaviour and emotional problems were significantly lower in children with PDD that did not meet DSM-5 criteria.

Psychiatric comorbidities in autism spectrum disorder: A comparative study between DSM-IV-TR and DSM-5 diagnosis

Background/Objective: The heterogeneous clinical presentations of individuals with Autism Spectrum Disorders (ASD) pose a significant challenge for sample characterization. Therefore the main goal of DSM-5 must be to identify subgroups of ASD, including comorbidity disorders and severity. The main goal of this study is to explore the psychiatric comorbidities and the severity of symptoms that could be relevant for the phenotype characterization in ASD and also to compare these results according to the different classification criteria between the DSM-IV-TR and the DSM-5. Method: A comparative study of severity and psychiatric comorbidities was carried out between a sample of participants that only met criteria for Pervasive Developmental Disorder (PDD) according to the DSM-IV-TR and a sample of participants that also met ASD criteria according to DSM-5 classification. The recruitment of children was via educational (N = 123). The psychiatric symptoms, comorbid disorders and severity of symptoms were assessed through The Nisonger Child Behavior Rating Form, clinical interview and The Inventory of Autism Spectrum Disorder, respectively. The psychiatric comorbidities considered were: anxiety, eating behavioural problems, self-aggressiveness, hetero–aggressiveness, self-harm, obsessive compulsive disorder and attention deficit and hyperactivity disorder. Results: Statistically significant differences between both groups were found regarding obsessive compulsive disorder, eating behavioural problems and severity. Conclusions: The results support the hypothesis that patients who meet the DSM-5 criteria have more severe symptoms, not only regarding the core autistic symptoms but also in relation with psychiatric comorbidities.

Visual function in autism spectrum disorders: a critical review

Studies have shown considerable evidence of visual dysfunction in autism spectrum disorders. Anomalies in visual information processing can have a major effect on the life quality of individuals with autism spectrum disorders. We summarise the hypotheses and theories underlying neural aetiologies and genetic factors that cause these disorders, as well as the possible influences of unusual sensory processing on the communications and behaviour characterised by the autistics. In particular, we review the impact of these dysfunctions on visual performance.

The Effects of DSM-5 Criteria on Number of Individuals Diagnosed with Autism Spectrum Disorder: A Systematic Review

A growing body of research has raised concerns about the number of individuals diagnosed with autism spectrum disorder (ASD) according to DSM-IV-TR who may no longer qualify for diagnoses under the new DSM-5 criteria, published in May 2013. The current study systematically reviews 25 articles evaluating samples according to both DSM-IV-TR and DSM-5 ASD criteria. Consistent with previous reviews, the majority of included studies indicated between 50 and 75% of individuals will maintain diagnoses. We conducted visual analyses of subgroups using harvest plots and found the greatest decreases among high-functioning populations with IQs over 70 and/or previous diagnoses of PDD-NOS or Asperger's disorder. We discuss the potential research and clinical implications of reduced numbers of individuals diagnosed with ASD.

Comparing Diagnostic Outcomes of Autism Spectrum Disorder Using DSM-IV-TR and DSM-5 Criteria

Controversy exists regarding the DSM-5 criteria for ASD. This study tested the psychometric properties of the DSM-5 model and determined how well it performed across different gender, IQ, and DSM-IV-TR sub-type, using clinically collected data on 227 subjects (median age = 3.95 years, majority had IQ > 70). DSM-5 was psychometrically superior to the DSM-IV-TR model (Comparative Fit Index of 0.970 vs 0.879, respectively). Measurement invariance revealed good model fit across gender and IQ. Younger children tended to meet fewer diagnostic criteria. Those with autistic disorder were more likely to meet social communication and repetitive behaviors criteria (p < .001) than those with PDD-NOS. DSM-5 is a robust model but will identify a different, albeit overlapping population of individuals compared to DSM-IV-TR.

DSM-5 changes and the prevalence of parent-reported autism spectrum symptoms in Fragile X syndrome

We used survey methodology to assess parent-reported autism symptomology in 758 individuals (639 males; 119 females) with fragile X syndrome (FXS). Caregivers reported whether their child with FXS had been diagnosed with an autism spectrum disorder (ASD) and endorsed symptoms based on a list of observable behaviors related to ASD diagnoses. Symptom counts were categorized based on DSM-IV-TR and DSM-5 criteria. Based on behavioral symptoms endorsed by caregivers, 38.7 % of males and 24.7 % of females met criteria for DSM-IV-TR diagnosis of autistic disorder. Significantly fewer males (27.8 %) and females (11.3 %) met criteria for ASD based on DSM-5 criteria. Although 86.4 % of males and 61.7 % of females met criteria for the restricted and repetitive behavior domain for DSM-5, only 29.4 % of males and 13.0 % of females met criteria for the social communication and interaction (SCI) domain. Relaxing the social communication criteria by one symptom count led to a threefold increase in those meeting criteria for ASD, suggesting the importance of subthreshold SCI symptoms for individuals with FXS in ASD diagnoses. Findings suggest important differences in the way ASD may be conceptualized in FXS based on the new DSM-5 criteria.

Treating aggression in persons with autism spectrum disorders: a review

Aggression is one of the most frequent and debilitating problems observed among persons with autism spectrum disorders (ASD). It is common and can be more problematic than many core symptoms of ASD. Thus, treating the behavior is a high priority. A surprisingly limited number of studies have addressed treatment when taken in the context of the vast ASD literature. This paper reviews many of these papers and describes the types of interventions that have been used and the characteristics of the people who have been studied.

How will DSM-5 affect autism diagnosis? A systematic literature review and meta-analysis

We conducted a systematic review and meta-analysis to determine the effect of changes to the Diagnostic and Statistical Manual (DSM)-5 on autism spectrum disorder (ASD) and explore policy implications. We identified 418 studies; 14 met inclusion criteria. Studies consistently reported decreases in ASD diagnosis (range 7.3-68.4%) using DSM-5 criteria. There were statistically significant pooled decreases in ASD [31% (20-44), p = 0.006] and DSM-IV-TR subgroups of Autistic disorder [22% (16-29), p < 0.001] and pervasive developmental disorder-not otherwise specified (PDD-NOS) [70% (55-82), p = 0.01]; however, Asperger's disorder pooled decrease was not significant [70% (26-94), p = 0.38]. DSM-5 will likely decrease the number of individuals diagnosed with ASD, particularly the PDD-NOS subgroup. Research is needed on policies regarding services for individuals lacking diagnosis but requiring assistance.

RETRACTED: How does ASD symptomology correlate with ADHD presentations?

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor in Chief, after review by an independent panel of experts, due to evidence of a compromised peer review process and the failure of one author to disclose significant conflicts of interest. An independent peer-review process is a cornerstone of scientific integrity that allows for research to be scrutinized before publication to ensure that conclusions are anchored in sound methodology and objective interpretation of the results. Equally important is that the readership of research is fully informed about any potential competing interests that may have influenced the research process. This article is being retracted because it did not include a declaration of a conflict of interest of one author in relation to diagnostic tools which the paper endorses. The same author was also the Editor in Chief of the journal at the time of publication and evidence indicates that the paper was accepted without any independent peer review by external reviewers. The article is therefore retracted in accordance with the ethical guidelines of Elsevier: https://www.elsevier.com/about/policies/publishing-ethics and the Committee on Publication Ethics (COPE) https://publicationethics.org/files/retraction-guidelines.pdf.

RETRACTED: An examination of the relationship between autism spectrum disorder, intellectual functioning, and comorbid symptoms in children

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor in Chief, after review by an independent panel of experts, due to evidence of a compromised peer review process and the failure of one author to disclose significant conflicts of interest. An independent peer-review process is a cornerstone of scientific integrity that allows for research to be scrutinized before publication to ensure that conclusions are anchored in sound methodology and objective interpretation of the results. Equally important is that the readership of research is fully informed about any potential competing interests that may have influenced the research process. This article is being retracted because it did not include a declaration of a conflict of interest of one author in relation to diagnostic tools which the paper endorses. The same author was also the Editor in Chief of the journal at the time of publication and evidence indicates that the paper was accepted without any independent peer review by external reviewers. The article is therefore retracted in accordance with the ethical guidelines of Elsevier: https://www.elsevier.com/about/policies/publishing-ethics and the Committee on Publication Ethics (COPE) https://publicationethics.org/files/retraction-guidelines.pdf.

Autism after DSM 5: the potential impact in one child's case

Max is a 21-month old boy with speech and language delay presenting for diagnostic clarification and treatment recommendations. Max was born at 37 weeks after a twin gestation. He is medically healthy and lives at home with supportive parents and a typically developing twin sister. Max began speech and language therapy when he was 14 months old.Max spoke his first word at 16 months. He uses fewer than 10 words or word approximations; however, he does not use these words spontaneously to communicate. Max has decreased use of eye contact and rarely uses nonverbal means of communication. Max whines but does not point or reference his parents to request their help when he wants something out of reach. Max responds to 1-step directions about 50% of the time. An audiology assessment was normal. Max does not bring objects of interest to show others, rarely initiates interactions and does not consistently respond to social overtures.Max is described as an easy-going child. He is content to play on his own and shows little interest in other children. He likes to spin wheels for the purpose of watching them. Max has no rigidities or rituals and is easy to redirect. He has no sensory seeking behaviors or aversions. He does not engage in any repetitive motor mannerisms.On formal evaluation, Max's cognitive skills were assessed within the average range; language and gross motor skills were below average. Performance on the Autism Diagnostic Observation Schedule, Toddler Module was concerning for an Autism Spectrum Disorder (ASD).Max's evaluation was concerning for deficits in social and communication functioning. A new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was recently published, resulting in a change in the diagnostic criteria for ASDs. Max meets criteria for autistic disorder under DSM, 4th edition, text revision (DSM-4-TR), but does not meet criteria for an ASD under DSM-5. Specifically by DSM-4-TR, he met all criteria under social interaction, 2 criteria under communication, and 1 under restricted and repetitive behaviors. By DSM-5, he met all of criteria A and just 1 of criteria B. How would you proceed diagnostically and what treatment recommendations would you make?

Update on diagnostic classification in autism

PURPOSE OF REVIEW

In the lead up to and following the recent publication of the DSM-5, the diagnostic construct of autism has received intense scrutiny.

RECENT FINDINGS

This article briefly reviews the history of the diagnosis of autism, the changes that have occurred in the diagnosis over time, and the rationale for change. The most significant changes being introduced with the DSM-5 are highlighted, as well as some of the concerns that will be a focus of attention with respect to the potential impacts going forward.

SUMMARY

The categorical divisions that characterized the pervasive developmental disorders are now collapsed into a single entity, autism spectrum disorder. The final DSM-5 criteria have yet to be formally compared prospectively against prior criteria, but early indications suggest that the boundaries around the pervasive developmental disorders have not been substantially altered.

Infants and toddlers with autism: the promise and the challenges

There has been a marked increase in interest in early identification of young children with and at risk for autism. This interest has reflected advances in research as well as an awareness of the potential for major changes in long-term outcome as a result of intervention. Several issues have complicated these efforts. There continue to be challenges to implementation of effective screening and diagnostic approaches in young children. Although the body of evidence-based research on treatment has increased, it remains limited. Despite these issues, important findings have emerged that may assist in fostering better approaches to screening, diagnosis, and documenting treatment impact.

The clinician's guide to autism

On the basis of the most recent epidemiologic research, Autism Spectrum Disorder (ASD) affects approximately 1% to 2% of all children. (1)(2) On the basis of some research evidence and consensus, the Modified Checklist for Autism in Toddlers isa helpful tool to screen for autism in children between ages 16 and 30 months. (11) The Diagnostic Statistical Manual of Mental Disorders, Fourth Edition, changes to a 2-symptom category from a 3-symptom category in the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition(DSM-5): deficits in social communication and social interaction are combined with repetitive and restrictive behaviors, and more criteria are required per category. The DSM-5 subsumes all the previous diagnoses of autism (classic autism, Asperger syndrome, and pervasive developmental disorder not otherwise specified) into just ASDs. On the basis of moderate to strong evidence, the use of applied behavioral analysis and intensive behavioral programs has a beneficial effect on language and the core deficits of children with autism. (16) Currently, minimal or no evidence is available to endorse most complementary and alternative medicine therapies used by parents, such as dietary changes (gluten free), vitamins, chelation, and hyperbaric oxygen. (16) On the basis of consensus and some studies, pediatric clinicians should improve their capacity to provide children with ASD a medical home that is accessible and provides family-centered, continuous, comprehensive and coordinated, compassionate, and culturally sensitive care. (20)

Diagnosing autism spectrum disorder: who will get a DSM-5 diagnosis?

BACKGROUND

Introduction of proposed criteria for DSM-5 Autism Spectrum Disorder (ASD) has raised concerns that some individuals currently meeting diagnostic criteria for Pervasive Developmental Disorder (PDD; DSM-IV-TR/ICD-10) will not qualify for a diagnosis under the proposed changes. To date, reports of sensitivity and specificity of the new criteria have been inconsistent across studies. No study has yet considered how changes at the 'sub domain' level might affect overall sensitivity and specificity, and few have included individuals of different ages and ability levels.

METHODS

A set of DSM-5 ASD algorithms were developed using items from the Diagnostic Interview for Social and Communication Disorders (DISCO). The number of items required for each DSM-5 subdomain was defined either according to criteria specified by DSM-5 (Initial Algorithm), a statistical approach (Youden J Algorithm), or to minimise the number of false positives while maximising sensitivity (Modified Algorithm). The algorithms were designed, tested and compared in two independent samples (Sample 1, N = 82; Sample 2, N = 115), while sensitivity was assessed across age and ability levels in an additional dataset of individuals with an ICD-10 PDD diagnosis (Sample 3, N = 190).

RESULTS

Sensitivity was highest in the Initial Algorithm, which had the poorest specificity. Although Youden J had excellent specificity, sensitivity was significantly lower than in the Modified Algorithm, which had both good sensitivity and specificity. Relaxing the domain A rules improved sensitivity of the Youden J Algorithm, but it remained less sensitive than the Modified Algorithm. Moreover, this was the only algorithm with variable sensitivity across age. All versions of the algorithm performed well across ability level.

CONCLUSIONS

This study demonstrates that good levels of both sensitivity and specificity can be achieved for a diagnostic algorithm adhering to the DSM-5 criteria that is suitable across age and ability level.

Brief report: comparability of DSM-IV and DSM-5 ASD research samples

Diagnostic and Statistical Manual (DSM-5) criteria for ASD have been criticized for being too restrictive, especially for more cognitively-able individuals. It is unclear, however, if high-functioning individuals deemed eligible for research via standardized diagnostic assessments would meet DSM-5 criteria. This study investigated the impact of DSM-5 on the diagnostic status of 498 high-functioning participants with ASD research diagnoses. The percent of participants satisfying all DSM-5-requirements varied significantly with reliance on data from the Autism Diagnostic Observation Schedule (ADOS; 33 %) versus Autism Diagnostic Interview-Revised (ADI-R; 83 %), highlighting the impact of diagnostic methodology on ability to document DSM-5 symptoms. Utilizing combined ADOS/ADI-R data, 93 % of participants met DSM-5 criteria, which suggests likely continuity between DSM-IV and DSM-5 research samples characterized with these instruments in combination.

Sensitivity and specificity of proposed DSM-5 criteria for autism spectrum disorder in toddlers

Autism spectrum disorder (ASD) diagnosis is based on behavioral presentation; changes in conceptual models or defining behaviors may significantly impact diagnosis and uptake of ASD-specific interventions. The literature examining impact of DSM-5 criteria is equivocal. Toddlers may be especially vulnerable to the stringent requirements of impairment in all three social-communication symptoms and two restricted/repetitive symptoms. Receiver operating characteristic (ROC) curves identified optimal cutoffs for sums of ADOS and ADI-R criteria mapped to each criterion for 422 toddlers. The optimal modification of DSM-5 criteria (sensitivity = 0.93, specificity = 0.74) required meeting the ROC-determined cutoffs for 2/3 Domain A criteria and 1 point for 1/4 Domain B criteria. This modification will help insure that ASD is identified accurately in young children, facilitating ASD-specific early intervention.

Narrowly versus broadly defined autism spectrum disorders: differences in pre- and perinatal risk factors

This study examined the differential contribution of pre- and perinatal risks in narrowly versus broadly defined autism spectrum disorder (ASD) and across core symptom domains, IQ and co-morbid problems. Children with a DSM-IV diagnosis of autistic disorder (AD) (n = 121) or pervasive developmental disorder not otherwise specified (PDD-NOS) (n = 75) were compared to a typical control sample (n = 311). Diagnoses were based on extensive assessments between 12 and 49 months of age (M = 33.3, SD = 6.4) and re-evaluated at 43-98 months (M = 68.1, SD = 10.7) in 70% of the cases. Compared with controls, cases with ASD were more likely to be firstborn and show a suboptimal condition after birth. Case mothers reported more infections and more stress during pregnancy. Although the ASD subgroups showed mostly overlapping risks, cases with PDD-NOS differed from those with AD by higher exposure to smoking during pregnancy (SDP) and by a negative association of smoking with IQ, regardless of confounders. SDP appears to contribute more to broadly defined (PDD-NOS) than to narrowly defined ASD (AD). Findings suggest differences in etiological contributors between ASD phenotypes.

Treating clients with Asperger's syndrome and autism

Asperger's syndrome (AS) is a form of autism spectrum disorder (ASD) affecting many individuals today. Although neurobiological correlates for AS have been identified, like many ASDs, AS is not completely understood. AS as a distinct disorder is also not universally accepted and in the DSM-5 AS is not considered a separate nosological entity. In contrast to some other ASDs, individuals with AS are commonly characterized by having standard or higher than average intelligence, yet difficulties in social skills and communication can present challenges for these individuals in everyday functioning. Counseling a person with AS or autism presents a unique challenge for the mental health care provider. We have compiled this review consisting of some recent ideas regarding counseling the client with AS with the goal of providing some clinical insights and practical clues. Although the focus of the present paper is largely on AS, many of these strategies could also apply to individuals with high-functioning autism (HFA).

The effect of DSM-5 criteria on the developmental quotient in toddlers diagnosed with autism spectrum disorder

OBJECTIVE

To determine the effect of the changing fifth edition of the Diagnostic and Statistical Manual (DSM-5) criteria on the developmental profiles of children diagnosed with an Autism spectrum disorder (ASD).

METHODS

This study examines the effect of DSM-5 changes on impairment profiles of a population of 2054 at-risk toddlers aged 17-36 months using the Battelle Developmental Inventory, Second Edition.

RESULTS

Toddlers diagnosed with an ASD according to the DSM-5 were found to represent a more impaired population compared to those who qualified for a diagnosis of an ASD based on the DSM-IV-TR, but not the DSM-5. The group diagnosed according to the DSM-IV-TR represented a population of toddlers who were more impaired than atypically developing peers.

CONCLUSIONS

The proposed changes to the DSM will likely result in those diagnosed with an ASD according to the new criteria representing a more functionally impaired group. Implications of this proposed change are discussed.

Mass spectrometry as a tool for studying autism spectrum disorder

Autism spectrum disorders (ASDs) are increasing in incidence but have an incompletely understood etiology. Tools for uncovering clues to the cause of ASDs and means for diagnoses are valuable to the field. Mass Spectrometry (MS) has been a useful method for evaluating differences between individuals with ASDs versus matched controls. Different biological substances can be evaluated using MS, including urine, blood, saliva, and hair. This technique has been used to evaluate relatively unsupported hypotheses based on introduction of exogenous factors, such as opiate and heavy metal excretion theories of ASDs. MS has also been used to support disturbances in serotonin-related molecules, which have been more consistently observed in ASDs. Serotonergic system markers, markers for oxidative stress, cholesterol system disturbances, peptide hypo-phosphorylation and methylation have been measured using MS in ASDs, although further analyses with larger numbers of subjects are needed (as well as consideration of behavioral data). Refinements in MS and data analysis are ongoing, allowing for the possibility that future studies examining body fluids and specimens from ASD subjects could continue to yield novel insights. This review summarizes MS investigations that have been conducted to study ASD to date and provides insight into future promising applications for this technique, with focus on proteomic studies.

Subgrouping the autism "spectrum": reflections on DSM-5

DSM-5 has moved autism from the level of subgroups ("apples and oranges") to the prototypical level ("fruit"). But making progress in research, and ultimately improving clinical practice, will require identifying subgroups within the autism spectrum.

A comparison of diagnostic criteria on the Autism Spectrum Disorder Observation for Children (ASD-OC)

BACKGROUND

The Autism Spectrum Disorder Observation for Children (ASD-OC) is a new observation scale used to assess autistic symptomatology. As the publication of the fifth edition Diagnostic and Statistical Manual (DSM) is approaching, exploring the effect of the changing DSM criteria has begun to occur.

OBJECTIVE

The aim of this study was to compare severity of autistic impairment in children diagnosed with either the DSM-IV-TR or the DSM-5.

METHODS

ASD-OC total scores were compared between 63 children (3-15 years) in one of three groups: DSM-IV-TR group, DSM-5 group or control group.

RESULTS

The DSM-5 and DSM-IV-TR groups evinced significantly higher ASD-OC scores as compared to the control group; however, there were no significant differences between the DSM-5 and DSM-IV-TR groups in symptom severity.

CONCLUSION

Many children who are currently diagnosed with ASD may no longer be diagnosed, despite having significant impairments roughly equal to those who meet DSM-5 criteria.

Exploring the proposed DSM-5 criteria in a clinical sample

The proposed DSM-5 criteria for Autism Spectrum Disorder (ASD) depart substantially from the previous DSM-IV criteria. In this file review study of 131 children aged 2-12, previously diagnosed with either Autistic Disorder or Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS), 63 % met the new DSM-5 ASD criteria, including 81 % previously diagnosed with Autistic Disorder and only 17 % of those with PDD-NOS. The proportion of children meeting DSM-5 differed by IQ grouping as well, with higher rates in lower IQ groups. Children who did meet criteria for ASD had significantly lower levels of cognitive and adaptive skills and greater autism severity but were similar in age. These findings raise concerns that the new DSM-5 criteria may miss a number of children who would currently receive a diagnosis.

How does relaxing the algorithm for autism affect DSM-V prevalence rates?

Although it is still unclear what causes autism spectrum disorders (ASDs), over time researchers and clinicians have become more precise with detecting and diagnosing ASD. Many diagnoses, however, are based on the criteria established within the Diagnostic and Statistical Manual of Mental Disorders (DSM); thus, any change in these diagnostic criteria can have a great effect upon children with ASD and their families. It is predicted that the prevalence of ASD diagnoses will dramatically decrease with the adoption of the proposed DSM-5 criteria in 2013. The aim of this current study was to inspect the changes in prevalence first using a diagnostic criteria set which was modified slightly from the DSM-5 criteria (Modified-1 criteria) and again using a set of criteria which was relaxed even a bit more (Modified-2 criteria). Modified-1 resulted in 33.77 % fewer toddlers being diagnosed with ASD compared to the DSM-IV, while Modified-2 resulted in only a 17.98 % decrease in ASD diagnoses. Children diagnosed with the DSM-5 criteria exhibited the greatest levels of autism symptomatology, but the Mod-1, Mod-2, and DSM-IV groups still demonstrated significant impairments. Implications of these findings are discussed.

The neuropathology of autism

Autism is a behaviorally defined neurodevelopmental disorder that affects over 1% of new births in the United States and about 2% of boys. The etiologies are unknown and they are genetically complex. There may be epigenetic effects, environmental influences, and other factors that contribute to the mechanisms and affected neural pathway(s). The underlying neuropathology of the disorder has been evolving in the literature to include specific brain areas in the cerebellum, limbic system, and cortex. Part(s) of structures appear to be affected most rather than the entire structure, for example, select nuclei of the amygdala, the fusiform face area, and so forth. Altered cortical organization characterized by more frequent and narrower minicolumns and early overgrowth of the frontal portion of the brain, affects connectivity. Abnormalities include cytoarchitectonic laminar differences, excess white matter neurons, decreased numbers of GABAergic cerebellar Purkinje cells, and other events that can be traced developmentally and cause anomalies in circuitry. Problems with neurotransmission are evident by recent receptor and binding site studies especially in the inhibitory GABA system likely contributing to an imbalance of excitatory/inhibitory transmission. As postmortem findings are related to core behavior symptoms, and technology improves, researchers are gaining a much better perspective of contributing factors to the disorder.

Classification of autism and related conditions: progress, challenges, and opportunities

Since Kanner's classic description of the syndrome of early infantile autism in 1943, conceptions of the disorder have evolved while retaining important continuity with what Kanner viewed as the hallmarks of the condition—social impairment (autism) and difficulties in dealing with change in the nonsocial world (insistence on sameness). This paper reviews the history of this evolution and the important potential advantages and disadvantages of changes being contemplated for DSM-5. The convergence of diagnostic approach in DSM-IV and ICD-10 provided a shared system that fostered a tremendous body of research. The changes proposed in DSM-5 may impact both research comparability and service eligibility.