DSM-V

1
DSM-V its Implications for Schools Families

• Prof Rita Jordan PhD OBE
• Emeritus Professor in Autism Studies
• University of Birmingham, UK
• Autism New Zealand Conference. Workshop Auckland,
  September 2012

2
Current Diagnosis

• ICD10 DSMIV - based on underlying triad of
  difficulties
• social emotional understanding
• communication
• flexibility in thinking behaviour
• ASD part of PDD
• autistic disorder (classical autism)
• Asperger syndrome
• atypical autism/ PDD-NOS
• DSM-V ICD-11 coming (2012)

3
DSM-V ICD-11

• PDD
• all to be ASD
• PDD-NOS gone
• Retts syndrome Hellers syndrome (CDD) medical
• ASD
• subcategories gone (i.e. no Asperger syndrome, no
  PDD-NOS)
• 2 dimensions not triad (social communication
  combined)
• both dimensions compulsory for ASD diagnosis

4
Dimensions

• move towards dimensions r.th. categories
• descriptors of place on each dimension as part of
  diagnosis
• better relates to needs led services
• cut-off makes dimensions -gt categories
• dimensional diagnostic tool DISCO (status of ADI
  ADOS?)

5
Sensory Issues

• evidence that at extremes -DSM-V will record
• both over- and under-responsive to different
  senses
• over-responsive sensory avoiding
  under-responsive sensory seeking
• shield from sensitivities and/or desensitise
• attach meaning to perception - reduce
  bombardment of meaningless stimulation
• aware of variability - use proximal blocks
• give environmental control to individual if
  possible
• reduce overall stress
• teach to monitor and manage levels of arousal

6
Co-Morbidities

• Wing Nature never draws a line without smudging
  it
• ASD rarely occurs as sole disorder
• additional developmental disorders later
  anxiety disorders
• current diagnostic hierarchy rules deny reality
• language disorder autism
• ADHD ASD
• expression of disorders affected by comorbid
  conditions

7
Problems in Current Systems

• sub categories poor validity
• social communicative linked
• inappropriate basis for services
• poor guide to prognosis and treatment
• boundary between PDD-NOS typical too vague
  and inconsistent
• AS assumed to mean mild autism but muddled with
  IQ
• separate dimensions of autism severity
  intelligence

8
Status of Diagnosis

• ASD may be family of dimensional phenotypes
  including
• symptoms (diagnostically differentiating)
• level of functioning
• psychiatric and medical co-morbidities
• NICE (2011) autism not just a medical
  diagnosis but a social/care responsibility
• Szatmari (2011) ASD - great heterogeneity of
• phenotypes
• outcomes
• risk factors

9
Reasons for Diagnosis

• to provide outcome status for research on causal
  pathways
• to develop and evaluate treatment
• to enable identity support /training for
  individuals, families and professionals
• to create cohesion and order among symptoms
• should not be for rationing of services-
  should be needs-led

10
Problems with DSM-V

• Mandy et al (2011) what will happen to PDD-NOS
  individuals?
• only 2/66 children with PDD-NOS would score as
  having ASD in DSM-V
• join social communication difficulties
  diagnosis but this is behaviour-based
• only interim stage until valid sub-groups

11
Problems with DSM-V (2)

• Partland et al (2012) - re diagnosed data from
  DSM-IV under DSM-V
• specificity good but sensitivity for AS PDD-NOS
  poor i.e. many of more able missed
• ignores language level within diagnosis yet
  research shows major outcome variable
• if language is outside diagnosis why is RSB in?

12
Personal Reactions?

• link with identity (usually AS)
• ASD of the Asperger type
• social reactions need to be anticipated and
  planned for
• adjustment period
• regular services not prepared
• specialist services too limited segregated
• individualisation not adequately trained
• break with categorical/ medical model
• ASC vs ASD?

13
Services post DSM-V

• fulfill all advice for needs-led services
• helps move towards integrated services
• reinforces responsibility of all
• special is understanding and approach - not
  location
• research shows best model is skilling of
  typical services
• fits recognition of prognosis depending on
  services, not just diagnosis
• better fit for individual at appropriate level

14
Individualisation

• move beyond rhetoric lip-service
• recognise individual differences important for
  education treatment
• sociability
• language disorder
• sensory responsiveness
• intelligence
• impulsivity (ADHD)

15
EBP vs EST

• Evidence Supported Treatment
• existing treatment
• evaluation of treatment
• Evidence Based Practice
• starts with individual
• evaluates what is best for individual
• takes account of EST process
• EBP supported by more individualised diagnosis

16
ASD as a Social Instinct Deficit

• Sigman et al (2004) qualitative social
  difficulties most universal specific dimension
  of ASD
• not TOM but need for TOM
• early aspects of social salience, joint
  attention, communication gestures etc
• sociability as individual not diagnostic factor
• supported by neurophysiology imaging as well as
  by treatment outcomes

17
Teaching about Emotions

• self then others
• explicit meaning through
• mirrors - attention to own
• unambiguous emotional expressions
• explicit labeling - external cues?
• context
• managing extreme emotional reactions
• enjoyable experiences enhance learning

18
Evidence

• no single approach
• evidence for
• structure
• broad modern behavioural methods
• training parents in social interaction
  communication techniques
• play-based early interventions (15 hrs/ week)
• in all studies some do well and some do not
• in all studies children tend to learn only what
  are explicitly taught

19
Reasons for challenging behaviour in ASD

• biology
• epilepsy
• perception/ sensory disturbance
• sensory deprivation
• reactions to pain
• lack of communication skills
• lack of self-awareness
• adaptation to the environment

20
Background Factors

• Diet
• peptide theory
• effects of diets
• Sleep
• chronic deprivation
• melatonin
• Exercise
• daily aerobic

21
Severe Types of Anxiety Disorders

• phobias
• panic attacks
• obsessive compulsive disorder
• post traumatic stress syndrome
• personality disorder

22
General Approach

• reduce stress by
• use of prosthetic devices
• increasing understanding
• improving coping skills
• accept nature of the autistic difficulties i.e.
  take perspective of person with ASD
• priority to communication interpersonal
  development

23
A Positive Approach

• move away from aversives
• understand meaning and function
• need positive alternative
• not inhibition
• teaching consequences
• structured setting
• accept phobias etc..

24
Practical issues

• reflection
• allow time
• include emotional context
• make pragmatically relevant
• real and informed choices
• menus
• flow charts for challenging behaviour
• positive experience of alternatives

25
Practical issues (cont)

• opportunities for control of others/ events
• with feedback
• external cueing of emotional states
• notice signs
• teach to person with ASD
• make relevant - i.e. lead to action

26
Changing Behaviour

• difficult to inhibit actions
• change the environment
• prevent the response train alternative
• develop self control (supports)
• functional analysis
• teach adaptive behaviours
• plan - do - reflect

27
Functional Analysis -autism specific

• Settings
• last straw not always trigger
• whole child (inc. skills) whole school approach
  
• parent collaboration
• Behaviour
• accurate
• frequency
• duration
• intensity
• Results

28
Making it worse

• transactional nature of autism
• frustration deskilling of carers
• literal reading of behaviour
• fear
• short-term success
• punishment may be a reward
• predictability is paramount

29
Potential Dangers

• whole notion of diagnosis may be lost in needs
  led services
• without autism awareness behaviour may be
  misunderstood
• specialisd input may be delayed until child has
  learnt to fail
• autism gives new meaning to behaviour and new
  urgency in developing appropriate interventions

30
Starting Off

• best to act as if the child has autism
• successful preemption of anxiety may prevent
  co-morbidities
• remediating behavioural abnormalities/
  differences may still leave the child vulnerable
• need to understand resilience, from longitudinal
  studies - need diagnosis to enable this
• need to work on understanding first, then give
  positive natural experiences in which learning is
  facilitated

31
Early Social/ emotional engagement

• more able to engage socially if structured
  through enjoyable activity
• mutually enjoyable activity increases
• social skills understanding
• communicative ability
• flexibility
• difference between lack of understanding and
  non-compliance
• need for parents and professionals to understand
  the condition from the start
• more able (with language) more misunderstood
  -fewer diagnosed?

32
Conclusion

• some logical changes but not allowed for social/
  personal reactions
• opportunity to re-focus on needs and individual
  differences
• chance to integrate diagnosis with assessment
  leading to individualised services
• ASC vs ASD to deal with expansion of numbers
• cognitive style vs disability