The video below is the section for Autism from Part 4 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 4, click HERE. To watch earlier lectures in this series, or register for our webinar series on DSM-5 and the EPPP, click HERE.
Transcript of DSM-5 EPPP Lecture Video: Autism (Within the Abnormal Domain)
NARRATIVE DEFINITION: Autism Spectrum Disorder is a neurodevelopmental disorder characterized by difficulties communicating and interacting in a variety of social contexts, restricted and repetitive behaviors or interests, and early onset of symptoms that ultimately cause clinically significant impairment in everyday functioning. A reliable diagnosis of Autism Spectrum Disorder may be made as early as age 2, but symptoms may be recognized earlier than 12 months, depending upon the severity.
Autism Spectrum Disorder is used to diagnose disorders that were previously classified separately including: autism, asperger’s syndrome, pervasive developmental disorder NOS, and childhood disintegrative disorder. The term “spectrum” is used with respect to the wide range of manifestations of the disorder that are determined by developmental level, chronological age, and severity of the autistic condition.
Severity level may be categorized as Level 1 “Requiring Support,” Level 2 “Requiring Substantial Support,” or Level 3 “Requiring Very Substantial Support.” Specifiers include 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, and with catatonia.
Impaired social functioning is manifested by the child’s inability to use and understand nonverbal behavior (i.e. eye-to-eye contact, body language, and facial expressions). Impaired social communication may also include (in individuals with high levels of intellectual functioning) an inability to understand humor, irony, or shades of meaning. Children with Autism Spectrum Disorder also do not form developmentally appropriate peer relationships, do not spontaneously attempt to share interests or enjoyment with others, and do not demonstrate social or emotional reciprocity. Children may seem oblivious to others. When they do interact, it is often in a mechanical way (e.g., peers may be viewed as tools for the child’s solitary play rather than equal participants).
During infancy, impairment in social functioning may be evident by resistance to or passive acceptance of cuddling, lack of smiling, and failure to respond to their caregivers’ voices, and a lack of “joint attention” (i.e., following a parent’s pointing to look at an object together). One possible explanation for the social impairments inherent in Autistic Disorder is that individuals with this disorder fail to develop a “theory of mind” (TOM); that is, they do not recognize that other people’s points of reference differ from their own.
Impairment in communication may be so severe that children with Autism Spectrum Disorder fail to develop any spoken language. A third or more of individuals with Autism Spectrum Disorder remain mute throughout their lives. People with this disorder who do acquire spoken language demonstrate a variety of speech abnormalities, including echolalia, reversal of pronouns, idiosyncratic (invented) language, failure to understand the pragmatics of language, and abnormal prosody.
Individuals with Autism Spectrum Disorder are often preoccupied with a few specific interests or activities. They may adhere to strict routines and demonstrate extreme distress at small changes in their environment or activities. Additionally, people with this disorder may engage in stereotyped motor behaviors such as flapping their hands or twisting their fingers. Behavioral symptoms associated with Autism Spectrum Disorder include impulsivity, physical aggression, self-injurious behaviors (especially during times of stress), clumsiness, difficulty transitioning between situations, hyperactivity, limited attention spans, and abnormal reactivity to sensory input.
Approximately 1% of the United States population have been diagnosed with ASD. Heritability estimates range from 37% to higher than 90% and about 15% of he cases are linked to a known genetic mutation. People with Autism Spectrum Disorder who have an IQ over 70 and begin using spoken language by age 5 have a better prognosis than others with the disorder. A comorbid diagnosis of epilepsy increases the risk of intellectual disability. About 70% those with ASD also have another comorbid mental health disorder. About 40% have more than one comorbid mental health disorder. Symptoms and impairments tend to be present across the entire lifespan.
The most effective treatments for intellectual disability (intellectual developmental disorder) are behavioral therapies such as Applied Behavioral Analysis. Treatment of intellectual disability (intellectual developmental disorder) is most beneficial when it begins very early in the child’s life; the parents are actively involved; 20 hours per week of intervention are applied; the interventions are implemented at home; and the child is provided a highly structured environment. Although pharmacological interventions are not primary interventions, first and second generation antipsychotic medications may be useful for diminishing aggressive tendencies, self-injurious behavior, and emotional lability; stimulants may help with enhancing attention and reducing impulsivity.
FLASHCARD:
1. A neurodevelopmental disorder characterized by:
A. Difficulties in communication and interacting in social contexts
B. Restricted and repetitive behaviors and interests
C. Early symptom onset causing clinically significant impairment in functioning
2. Reliable diagnosis:
A. As early as age 2, some symptoms recognizable before 12 months
B. Better prognosis: IQ over 70 and begin spoken language by age 5
C. Symptoms and impairments occur across lifespan
3. Severity level:
A. Level 1: “Requiring Support”
B. Level 2: “Requiring Substantial Support”
C. Level 3: “Requiring Very Substantial Support”
4. Specifiers:
A. With or without accompanying intellectual impairment
B. With or without accompanying language impairment
C. Associated with a known medical or genetic condition or environmental factor
D. Associated with another neurodevelopmental, mental, or behavioral disorder
E. With catatonia
5. Impaired social functioning:
A. possible explanation for social impairments is the failure to develop a Theory of Mind (TOM): others’ points of reference not recognized as differing from their own
A. Infancy:
i. resistance/passive acceptance of cuddling, lack of smiling, non-response to care-givers voice, lack of “joint attention”
B. Childhood:
i. inability to use and understand nonverbal behaviors (eye-to-eye contact, body language, facial expressions)
ii. inability to understand humor, irony, shades of meaning
iii. failure to form developmentally appropriate peer relationships, don’t share interests/enjoyment with others, no social or emotional reciprocity, may seem oblivious to other
iv. interactions may appear mechanical
6. Impaired Communication
A. Speech abnormalities: echolalia, pronoun reversal, indiosyncratic language, failure to understand language pragmatics, abnormal prosody
B. Severe level may fail to develop spoken language (1/3 or more remain mute)
7. Impairment Behaviorally
A. Preoccupied with a few specific interests or activities
B. Adhere to strict routines, distress at small changes in environment/activity
C. Sterotyped motor behaviors: flapping hands, twisting fingers
D. Impulsivity, physical aggression, self-injurious behaviors, clumsiness, transition difficulties, hyperactivity, limited attention span, abnormal reactivity to sensory input
8. Comorbid Disorders
A. High comorbidity with seizure disorder (epilepsy) and intellectual disability
B. 70% have one comorbid mental disorder
C. 40% have more than one comorbid mental disorder
9. Effective Treatments:
A. Intellectual disability: Behavioral therapies, e.g., Applied Behavioral Analysis
i. Most beneficial: begun early, parents involved, 20 hours/wk, interventions carried over to home, highly structured environments
B. Behavioral impairments: (Pharmocological interventions not primary intervention)
i. First and second generation antipsychotic medications: agressive tendencies, self-injurious behaviors, emotional liability
ii. Stimulants: enhance attention and reducing impulsivity
10. Autism Spectrum Disorder: includes disorders previously classified separately (Autism, Asperger’s Syndrome, Pervasive Developmental Disorder NOS, and Childhood Disintegrative Disorder), and is used with respect to wide range of manifestations of the disorder as determined by developmental level, chronological age, and severity of autistic condition.
QUESTION:
Which of the following children with Autism Spectrum Disorder is likely to have the best prognosis?
ANSWERS:
A. Lacey, an 8-year-old girl with mild language delays, was diagnosed at age 7, has an IQ of 80 and is being treated with stimulant medication.
B. Donovan, a 6-year-old boy who was diagnosed at age 5, has recently started speaking, has an IQ of 75 and is being treated with Behavioral Therapy at home.
C. Anya, a 5-year-old girl with language deficiencies, who was diagnosed two months before her fifth birthday, has an IQ of 75 and is being treated with Cognitive-Behavior Therapy at an out-patient clinic.
D. Donald, a 7-year-old boy who was diagnosed at age 6, has not yet developed language, has an IQ of 80, and it being treated with interventions at home for 20 hours a week.
RATIONALE: B is correct, as early diagnosis and intensive in-home behavioral treatment are linked to improved outcomes. Also, girls are more likely to experience intellectual disability co-morbid with Autism Spectrum Disorder and therefore males may have a better prognosis. Language delays and an older age at the time of diagnosis (A) and (D) result in a lower prognosis. Cognitive Behavior Therapy outside the home (C) would not be linked to a higher prognosis compared to Behavioral Therapy at home (B).