Developmental Screening In Pediatric And Primary Care Practice
Integrating routine developmental screening into the practice setting can seem daunting. Following are suggestions for integrating screening services into primary care efficiently and at low cost, while ensuring thorough coordination of care.
An example of how developmental screening activities might flow in your clinic:
Involving Families in Screening
Research indicates that parents are reliable sources of information about their childrens development. Evidence-based screening tools that incorporate parent reports can facilitate structured communication between parents and providers to discover parent concerns, increase parent and provider observations of the childs development, and increase parent awareness. Such tools can also be time- and cost-efficient in clinical practice settings.2,3,4 A 1998 analysis found that, depending on the instrument, the time for administering a screening tool ranged from about 2 to 15 minutes, and the cost of materials and administration ranged from $1.19 to $4.60 per visit.5
Cognitive And Adaptive Functioning
In addition to assessing whether or not a comorbid classification of ID is warranted, an individuals abilities within cognitive domains should also be assessed . Another key consideration may be patterns of discrepancy between cognitive and adaptive abilities, as some individuals with ASD have difficulty with daily living skills despite having adequate cognitive skills.
Screening And Diagnosis Of Autism Spectrum Disorder For Healthcare Providers
Developmental screening can be done by a number of professionals in health care, community, and school settings. However, primary health care providers are in a unique position to promote childrens developmental health.
Primary care providers have regular contact with children before they reach school age and are able to provide family-centered, comprehensive, coordinated care, including a more complete medical assessment when a screening indicates a child is at risk for a developmental problem.
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What Should Researchers Do
In an effort to increase the specificity of the diagnostic criteria, DSM-5 identifies both core diagnostic symptoms and non-ASD-specific characteristics that vary within ASD populations. Taken together, these revisions encourage researchers to take a dimensional approach when studying the heterogeneous autism phenotype, similar to approaches that have been used in population samples. Because of variations in samples , no single study will be sufficient to accurately define ASD subgroups, but the emerging accumulation of research can begin to bolster understanding in this area. However, in order to advance in this line of inquiry, is it essential that researchers use adequate sample characterization. In an effort to provide guidance to researchers, Figure illustrates the proposed DSM-5 criteria. In the next section, we expand on this list and highlight the associated features that researchers should consider when characterizing their ASD samples.
Proposed Diagnostic and Statistical Manual of Mental Disorders, 5th edition criteria and associated features to be considered when characterizing autism spectrum disorder samples.
Restricted Interests And Repetitive Behaviours
- Rituals and repetitive behaviours cause significant interference and difficulty in their daily lives and general functioning.
- This disruption affects more that one area of their lives.
- A resistance of any attempt by others to be distracted from their fixated interest.
Children and People assigned to this level would defiantly be at the high end of the spectrum, namely what was earlier referred to as Aspergers Syndrome.
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Autism Spectrum Disorder 29900
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history :
Asd Criteria And Manifestations In Adults
The DSM-5 specifies diagnostic critera for ASD.24 The following table summarizes the DSM-5 criteria, with examples of how these criteria may manifest in adults.22
Though the DSM-5 conceptualizes ASD primarily as a social-communication disorder, there is a growing literature supporting the hypothesis that ASD is primarily characterized by differences in information processing.23 See, for example, the intense world theory of ASD.
Adults on the autism spectrum may display autistic traits differently from children. Most people, regardless of whether or not they are on the autism spectrum, mature and behave differently as they get older. As such, adults on the spectrum may not fit society’s images of autistic children. In addition, adults often find coping strategies that help them function in the world, but that may make autistic traits harder to recognize.
There is great heterogeneity in the clinical presentation of ASD. Although anyone on the spectrum would be expected to have challenges with social communication, these challenges can show up in many different ways. For example, a person may not be able to speak, may misunderstand facial expressions and body language, or may take language too literally. A person may have difficulty starting a conversation, may need more time alone than most people, or may feel uncomfortable socializing with others without a planned activity.
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Changes In Naming Conventions
Revisions in commonly used terminology required an evaluation of the most appropriate terms for describing some mental disorders an issue of particular concern for consumer-advocate organizations. The term mental retardation underwent several draft changes before the name intellectual disability was approved. The joint naming convention reflects use of the term intellectual disability in US law , in professional journals, and by some advocacy organizations, while the parenthetical term maintains language proposed for ICD-11 . As described previously, the terms substance abuse and substance dependence have been removed and are now replaced jointly by substance use disorder. The name of the substance chapter itself was altered to include the term addictive, matching a proposed ICD-11 naming convention, which refers to inclusion of gambling disorder as a behavioral syndrome with symptoms and pathophysiology largely mirroring those in substance-related disorders. Also in keeping with ICD language, the not otherwise specified categories in the DSM-IV have been renamed and reconceptualized as other specified and unspecified categories in the DSM-5.
One Should Remember Dsm Is Not A Diagnostic Tool But Rather A Tool Providing Criteria For Diagnosis
Common Tools for Diagnosis of Autism for Children Over 2 Years Old:
- ADOS Autism Diagnostic Observation Scale
- ADI-R Autism Diagnostic Interview Revised
It is critically important that the diagnostic process takes place at a number of meetings, over several days, so that the child is observed in different situations, at different hours of the day, in order to eliminate the influences of shyness, anxiety, fatigue, hunger, tension, boredom, etc.
Diagnosis of Autism Tools for Toddlers from 18 months to 24 months old:
- ADOS-3-T
- M-CHAT Modified Checklist for Autism in Toddlers
Screening Tool for Infants at Risk for Autism Under 18 Months Old:
- ESPASI Early Signs of Pre-Autism Scale for Infants, a screening tool developed by the Mifne Center in 2007 as a result of long-term studies on autism in infants.
Assessment and Treatment of Infants is the Expertise of The Mifne Center.
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What Do All These Results Mean
As noted previously there are some very sensible and praiseworthy aspects of DSM-5. The decision to eliminate subcategories is controversial, and the important thing is that individuals who need and benefit from services are still able to obtain these services. It is also imperative that we do not have major changes in research diagnosis. This would pose a significant challenge for many studies for example, those with epidemiological or longitudinal samples, or studies of treatments that span decades. It is also unclear what changes will be made in ICD-11 and a lack of alignment of the international and American definitions could impact research. It would seem to be important to base what may be significant change on a very solid body of data.
One might ask what we really know the actual impact of DSM-5 will be. The simple response is that we do not know . As we have outlined, a series of studies suggest that many children might no longer meet the diagnostic criteria of ASD. Less is known about very young children, which we would like to capture early to provide early intervention services when the brain has its most plasticity, or adults, who are an understudied population in which little is known regarding best practice. A very recent study has suggested that the DSM-5 approach is overly restrictive with this age group as well and became adequate only when scoring rules were modified .
Criteria For Social Communication Disorder Diagnosis
Social communication disorder is similar to autism spectrum disorder. The main difference is that children diagnosed with SCD dont have restricted, repetitive and/or sensory behaviour.
If children have at least two restricted, repetitive and/or sensory behaviours, it could point to a diagnosis of autism spectrum disorder. If not, it could point to a diagnosis of SCD.
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Diagnosis Of Autism From Kanner To Dsm
The condition known as autistic disorder, childhood autism, or infantile autism was first described by Kanner in his report of 11 children with what appeared to him to be a novel condition characterized by two essential features of autism a lack of interest in the social world, and a group of behaviors he referred to as resistance to change or insistence on sameness . Kanners thoughtful clinical description noted many of the features still commonly included in diagnostic criteria for the disorder, and his emphasis on the centrality of social difficulties remains a hallmark of the condition. Early research was confused by some false leads and a lack of clarity about the validity of autism . By the 1970s longitudinal and other studies strongly suggested the validity of the condition, its frequent association with intellectual disability, and its strong brain and genetic basis .
In DSM-III autism was included in a class of conditions called pervasive developmental disorder this term had the advantage of no previous history. The DSM-III definition was very focused on infantile autism and developmental change was only cursorily addressed, although other categories for late-onset autism were also included .
Referrals For Therapies And Assistive Technologies
Though there is greater attention to, and controversy about, therapies intended to treat ASD in children, providers often under-utilize referrals for therapies, services, and assistive technologies for adults on the autism spectrum. Such therapies, services, or technologies are not meant to treat or cure autism, but can potentially help adults on the autism spectrum improve function or quality of life. The aim is to help patients address challenges, increase coping strategies, treat co-occurring conditions, or obtain needed accommodations or supports. Participation in therapy should be the patient’s choice.
The following are a few examples where providers may consider referring adult patients on the autism spectrum for additional therapies, services, or assistive technologies.
Many individuals who have limited speech can benefit from the use of assistive and augmentative communication technology, such as picture boards or text-to-speech devices. There are countless examples of individuals who could not communicate effectively until they learned to use assistive technology as adults. Typically, such patients’ intellectual capabilities are under-estimated. Patients also may continue to develop and mature well into adult life. Failed attempts to use assistive communication in the past should not preclude reconsideration of a referral for adult patients with limited communication skills.
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What Is Autism Spectrum Disorder
Autism Spectrum Disorder , hereafter referred to as Autism , is a complex, lifelong developmental condition that typically appears during early childhood and can impact a persons social skills, communication, relationships, and self-regulation. The Autism experience is different for everyone. It is defined by a certain set of behaviors and is often referred to as a spectrum condition that affects people differently and to varying degrees.
While there is currently no known single cause of Autism, early diagnosis helps a person receive resources that can support the choices and opportunities needed to live fully.
What Are The Dsm
In 2013, the American Psychiatric Association released the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders .
The DSM-5 is now the standard reference that healthcare providers use to diagnose mental and behavioral conditions, including autism.
By special permission of the American Psychiatric Association, you can read the full-text of the new diagnostic criteria for autism spectrum disorder and the related diagnosis of social communication disorder below.
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Diagnostic Criteria For Autism Spectrum Disorder In The Dsm
DSM stands for Diagnostic and Statistical Manual of Mental Disorders, which is a manual published by the American Psychiatric Association. The manual includes classifications of psychiatric disorders for use by medical and mental health professionals. Clinicians may refer to versions of the DSM to look for diagnostic codes of different disorders and examine criteria for diagnosis. About 25% of the disorders are specific to children and are in the section of Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence. Autism and related disorders have been specifically included in different versions of the DSM since 1980.
The latest edition of the DSM, DSM-5, made significant changes to the diagnostic criteria for autism and related disorders. In DSM-IV, five separate diagnoses were classified under the heading Pervasive Development Disorders: Autistic disorder, Asperger Syndrome, Pervasive Development Disorder Not Otherwise Specified , Rett Syndrome, and Childhood Disintegrative Disorder. The Pervasive Development Disorder category no longer appears in DSM-5, and Autistic disorder, Asperger Syndrome, and PDD-NOS have now been combined into one label: Autism Spectrum Disorder .
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How Does This Affect Those With Asd
The big questions in all of our minds were So, how does this affect services for people with ASD? Will people be underdiagnosed? Will services be lost? Will it be more functional and aid diagnosis, or will it have a detrimental effect?
The data seem to be coming in gradually on this. So far, verbal reports Ive been pestering clinicians whenever I run into them! and early data are promising. A study reported by Tamara Dawkins, Allison T. Meyer, and Mary E. Van Bourgondien with Division TEACCH at the University of North Carolina suggested that the majority of people with Pervasive Developmental Disorder are not likely to be affected by the changes in DSM-5.
Perhaps as importantly, I have yet to hear any horror stories about people losing services. More information must be gathered before we all relax though. In particular, it will be interesting to learn what is happening to people who in the past would have received an Aspergers Syndrome diagnosis. Will they continue to find services? It was a wise move to grandfather in those people who carried that diagnosis under the DSM-IV, but what is happening to other people now with the same characteristics? We need to keep a close watch. Im optimistic, but cautious.
Aleck Myers, Ph.D., LP, HSP, can be reached at .
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Research To Drive The Future Of Autism
Nevertheless, no matter how controversial these changes are, they were based on sound research, analysis and expert opinion. The aim of the changes to the DSM 5 for Autism Spectrum Disorder, were made in the hope that diagnosing Autistic disorders would be more reliable, more specific and hold more validity by standing the test of time.
There is apprehension as to how the changes will impact people who will no longer meet the stricter criteria for diagnosis, especially people at the higher end of the spectrum. Will they still be eligible for the support that they have had within education? This is concerning especially as it is likely that they also have additional learning difficulties.
Obviously, these changes will have an impact not just on the people who are diagnosed with Autism, but also their families.
Since the publication of the Autism Spectrum Disorder DSM 5, scientists have found that there is distinct brain connectivity difference between children with Autism in comparison with children who have other forms of Autism. A specific example is where that children with Aspergers do not have a speech delay but children with other forms of Autism do.
Risks And Benefits Of Adult Diagnosis
Many adults who meet diagnostic criteria for ASD do not carry formal medical diagnoses of ASD, either because they have never come to medical attention or because they have been misdiagnosed with a differential condition . When deciding whether to refer an adult patient for a diagnostic evaluation for ASD, one should consider potential risks and benefits of a diagnosis, and should discuss these possibilities with the patient and, if applicable, their supporters.
Potential benefits of a formal diagnosis are as follows.
- Would confer legal rights to accommodations in school, at work, in healthcare, or in other settings.
- May assist the individual in developing a better understanding of self.
- May provide peace of mind through the professional confirmation of life experiences.
- May provide means to experience better coping or quality of life by more directly helping in recognizing strengths and accommodating challenges.
- May provide others means to understand and support the individual.
- May qualify the individual for benefits and services for people who have an ASD diagnosis.
- May qualify the individual for programs for people with disabilities, such as scholarships or incentives that are meant to increase workplace diversity.
Potential risks associated with seeking an ASD diagnosis are as follows.
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