DSM Frye EAC.ppt

1. Using the Diagnostic Statistical Manual
of Mental Disease in the Diagnosis
of Autism Spectrum Disorder
Richard E. Frye, M.D., Ph.D.
Chief, Section on Neurodevelopment Disorders
Director, Autism and Fragile X Programs
Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix AZ
Professor of Child Health
University of Arizona College of Medicine, Phoenix AR

2. Disclosures
•None

3. • “Autism” termed
• Derived from Freud’s
‘autoerotism’
• hallucinatory thinking with
self-soothing which preceded
the infant’s engagement with
external reality
• Bleuler described as
“thinking…no longer bound
by the rules of logic”
• Book: Infantile Autism:
The Syndrome and Its
Implications for a Neural
Theory of Behavior
• Founder
• Autism Research
Institute
• Autism Society of
America
• Book: The Empty
Fortress: Infantile
Autism and the
Birth of the Self
• Refrigerator
mothers theory
• Traumatized
unloved child
retreated into
autism

4. Early Abnormalities in
Development
Related to
Autism Spectrum Disorder

5. Typical Child Development
Motor
• Cephalocaudal, proximo-distal
• Not typically major delays with ASD
Language
• Receptive and Expressive
• Receptive good “window” into cognitive

6. Protodeclarative
Protoimperative
•Desired Object
•Impaired in young ASD
•May develop in older ASD
• Shared Experience
• Joint Attention
• Deficient in ASD
• Pointing
• Starts Around 8-10 Months
• Majority of Gestures at 12 Months
• Other Protodeclarative Gestures
• Showing
• Giving:

7. Play Milestone Typical Age of
Development
Exploratory play
mouths, manipulates and inspects objects
8 -12 months
Functional play
Uses objects appropriately on self
12 – 18 months
Representational play
Pretends to use object on others (e.g. doll)
18 – 20 months
Symbolic Play
Use of an object to represents another during
pretend play, imitative play
3 years
Play Skill Development is a Excellent Sign of Typical Development.
More advanced play such as representational and symbolic play are
deficient in autism.

8. Retrospective Videotape Analysis of First Birthday
• Landmark study in 1994 by Osterling and Dawson
– Decrease in four behaviors differentiated 10 of 11 ASD
children from 11 normally developing children
• Pointing
• Showing objects
• Looking at Other People
• Orienting to Name
• Osterling 2002 compared Autism vs Intellectual Disability vs
Typically Developing
– Only Autism vs Typical
• Looked at Other People Less
• Oriented to their Names Less
– Autism and/or Intellectual Disability vs Typical
• Used Gestures Less
• Looked at Objects Held by Other People Less
• Engaged in Repetitive Motor Movements More

9. Retrospective Parental Questionnaires
• Vostanis et al (1998)
– Compared ASD vs Learning Disabilities vs Language
Disorders
– Questionnaire about behaviors at 12 to 18 months of age
– ASD children more problems with social attention and
communication
• Imitation
• Pointing at objects
• Playing Peek-a-boo
• Seeking and enjoying cuddling
• Checking for parents
• Interest in other children
• Waving bye-bye without being asked

10. Retrospective Parental Questionnaires
• Early Development Interview (2006)
– Structured Interview regarding development
between birth and 2 years of age
– ASD compared to Developmental Delay vs Typical
• More Social Deficits than Typically Developing at 3-6 months
• More Social Deficits than Developmental Delayed at 13-15 months
– Poor Eye Contact
– Reduced Orienting to Name
– Decreased Joint Attention
– Decreased Social Interactions

11. Retrospective Parental Questionnaires
• First Year Inventory (2003)
– Questionnaire focusing on development before 12 months
– ASD compared to Developmental Delay vs Typical
• ASD vs Developmental Delay
– Responding to Name
– Following someone pointing
– Social orientation
– Social Smiling
– Playing Peek-a-boo
– Demanding attention
• ASD and Developmental Delay vs Typically Developing
– Imitation
– Expressive Communication
– Repetitive Behaviors

12. Early Abnormalities in
Cognitive Development
in
Autism Spectrum Disorder

13. Landa and Garrett-Mayer (2006)
• Assessed 87 Infants at 6, 14 and 24 Months using
the Mullen Scales of Early Learning
– Gross and Fine Motor Development
– Visual reception
– Receptive and Expressive Language
• Typically Developing, Language Delayed and ASD
– 6 Months: No Difference Between Groups
– 14 Months: ASD was worse than Typically
Developing
• Gross and Fine Motor Development
• Receptive and Expressive Language
– 24 Months: ASD worse than Typically Developing
• All Areas
– 24 Months: ASD worse than Language Delayed
• Gross and Fine Motor Development
• Receptive Language

15. Early Abnormalities in
Visual Attention
In
Autism Spectrum Disorder

16. Upright
Inverted
Point-Light Animation

17. Movie of a Familiar Caregiver
Autism, 15 Months Typical, 15 Months Typical, 9 Months

20. ASD, 6 Months Typical, 6 Months Fixation on Eyes in Movie

21. The Diagnosis Criteria:
The Diagnostic Statistical
Manual of Mental Disorders

23. DSM IV Criteria:
Pervasive Developmental
Disorders
Autistic Disorder
Asperger’s Disorder
Rett’s Disorder
Childhood Disintegrative Disorder
Pervasive Developmental Disorder Not Otherwise
Specified

25. DSM-IV-TR

26. DSM IV Criteria:
Autistic Disorder
CORE SYMPTOM DOMAINS
1) Impairment in Social Interaction
2) Impairment in Communication
3) Restricted repetitive patterns of behavior,
interests, and activities
Leo Kanner

27. Autistic Disorder
Symptom criteria met before the age of 3 years
Boys:Girls = 4:1
75% have comorbid intellectual disability
Nearly 30-50% never develop functional verbal
communication
33% eventually develop seizure disorder

28. Age of Onset
Autistic Disorder and Pervasive Development Disorder
• By Definition (DSM-IV/ICD-10) – Before 36 Months – Three patterns
• 33% Regression from normal development
• Usually Between 12 and 24 months
• 33% Symptoms from Early Infancy
• 33% Symptoms obvious after 1 year old – developmental plateau
• Onset after 36 months – other diagnosis
• Regression after 36 months Childhood Disintegrative Disorder
Asperger’s Syndrome
• No Age Criteria for diagnosis
• Typically not diagnosed until later childhood because less obvious
when language development is normal.

29. DSM IV Criteria: Asperger’s Disorder
Impairment in Social Interaction
Restricted repetitive patterns of
behavior, interests, and activities
No clinically significant delay in
language
No clinically significant delay in
cognitive development
“All-encompassing” preoccupation
Hans Asperger

30. Rett’s Syndrome
Females
Deceleration of head growth
Stereotyped hand movements
Loss of purposeful hand skills
Loss of social engagement
Severe language disorder
Severe to profound intellectual disability
Andreas Rett

31. Childhood Disintegrative
Disorder
Normal Development for ≥ 2 years
Significant loss of previously acquired skills (before
age 10 years)
Abnormalities in 2 of 3 areas:
- Social
- Communication
- Repetitive behavior

32. DSM IV Criteria:
PDD NOS
Presentations that do not meet the
criteria for Autistic Disorder because of
late age of onset, atypical
symptomatology, or subthreshold
symptomatology, or all of these.

35. DSM-IV-TR
Autistic Disorder
DSM-5
Autism Spectrum Disorder
CORE SYMPTOM DOMAINS
1) Impairment in Social
Interaction
2) Impairment in Communication
3) Restricted repetitive patterns of
behavior, interests, and
activities
CORE SYMPTOM DOMAINS
1) Impairment in Social Communication
and Interaction (all 3)
a) Deficits in reciprocity
b) Deficits in nonverbal communication
c) Difficulties in relationships
2) Restricted repetitive patterns of
behavior, interests, and activities
a) Stereotyped/repetitive movements, play,
speech
b) Insistence on sameness
c) Restricted, fixed interests
d) Hyper/hyporeactivity to stimuli

37. • A. Persistent deficits in social communication and social interaction
across multiple contexts, as manifested by ALL of the following
1. Deficits in social-emotional reciprocity, ranging, for example, from
abnormal social approach and failure of normal back-and-forth
conversation; to reduced sharing of interests, emotions, or affect; to
failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social
interaction, ranging, for example, from poorly integrated verbal and
nonverbal communication; to abnormalities in eye contact and body
language or deficits in understanding and use of gestures; to a total
lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships,
ranging, for example, from difficulties adjusting behavior to suit various
social contexts; to difficulties in sharing imaginative play or in making
friends; to absence of interest in peers.

38. • B. Restricted, repetitive patterns of behavior, interests, or activities, as
manifested by at least TWO of the following:
1. Stereotyped or repetitive motor movements, use of objects, or speech
(e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia,
idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized
patterns of behavior (e.g., extreme distress at small changes, difficulties
with transitions, rigid thinking patterns, greeting rituals, need to take same
route or eat food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus
(e.g, strong attachment to or preoccupation with unusual objects,
excessively circumscribed or perseverative interest).
4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory
aspects of the environment (e.g., apparent indifference to
pain/temperature, adverse response to specific sounds or textures,
excessive smelling or touching of objects, visual fascination with lights or
movement).

39. C. Symptoms must be present in the early developmental period
(but may not become fully manifest until social demands exceed
limited capacities or may be masked by learned strategies in later
life. – NO SPECIFIC AGE
D. Symptoms cause clinically significant impairment in social,
occupational, or other important areas of current functioning. –
Functional Impairment
E. These disturbances are not better explained by:
1) Intellectual disability
Can co-occur but social communication should
be below that expected for developmental level.
2) global developmental delay.

40. Need to Specify:
•With or without accompanying intellectual impairment
•With or without accompanying language impairment
• (Coding note: Use additional code to identify the associated
medical or genetic condition.)
•Associated with another neurodevelopmental, mental, or
behavioral disorder
• (Coding note: Use additional code[s] to identify the associated
neurodevelopmental, mental, or behavioral disorder[s].)
•With catatonia
•Associated with a known medical or genetic condition or
environmental factor

41. Level 1 "Requiring support”
Social-Communication
Without supports in place, deficits in social communication cause noticeable
impairments. Difficulty initiating social interactions, and clear examples of
atypical or unsuccessful response to social overtures of others. May appear to
have decreased interest in social interactions. For example, a person who is able
to speak in full sentences and engages in communication but whose to- and-fro
conversation with others fails, and whose attempts to make friends are odd and
typically unsuccessful.
Restricted, repetitive behaviors
Inflexibility of behavior causes significant interference with functioning in one or
more contexts. Difficulty switching between activities. Problems of organization
and planning.

42. Level 2 "Requiring substantial support”
Social-Communication
Marked deficits in verbal and nonverbal social communication skills; social
impairments apparent even with supports in place; limited initiation of social
interactions; and reduced or abnormal responses to social overtures from
others. For example, a person who speaks simple sentences, whose interaction is
limited to narrow special interests, and how has markedly odd nonverbal
communication.
Restricted, repetitive behaviors
Inflexibility of behavior, difficulty coping with change, or other
restricted/repetitive behaviors appear frequently enough to be obvious to the
casual observer and interfere with functioning in a variety of contexts. Distress
and/or difficulty changing focus or action.

43. Level 3 "Requiring very substantial support”
Social-Communication
Severe deficits in verbal and nonverbal social communication skills cause severe
impairments in functioning, very limited initiation of social interactions, and
minimal response to social overtures from others. For example, a person with
few words of intelligible speech who rarely initiates interaction and, when he or
she does, makes unusual approaches to meet needs only and responds to only
very direct social approaches
Restricted, repetitive behaviors
Inflexibility of behavior, extreme difficulty coping with change, or other
restricted/repetitive behaviors markedly interfere with functioning in all spheres.
Great distress/difficulty changing focus or action.

44. Major Diagnostic Changes
•1) PDD NOS, Autistic Disorder and Asperger’s Disorder are all
combined into one disorder Autism Spectrum Disorder
• 2) Impairment in verbal communication is no longer a
diagnostic criterion
• 3) A new diagnostic criterion is the presence of hyper or
hyporeactivity to sensory stimuli or unusual sensory interest
• 4) No Specific age of onset is defined, simply symptoms need
to be present in early developmental period

45. Major Diagnostic Changes
• 5) ASD has mild, moderate, severe modifier depending on
support needed for each core symptom domain
• 6) Functional impairment needs to be considered and
documented
• 7) Attention-Deficit Hyperactivity Disorder can Co-Occur

46. Social (Pragmatic) Communication Disorder
A. Persistent difficulties in the social use of verbal and nonverbal communication as
manifested by all of the following:
1. Deficits in using communication for social purposes, such as greeting and sharing
information, in a manner that is appropriate for the social context.
2. Impairment of the ability to change communication to match context or the needs of
the listener, such as speaking differently in a classroom than on the playground, talking
differently to a child than to an adult, and avoiding use of overly formal language.
3. Difficulties following rules for conversation and storytelling, such as taking turns in
conversation, rephrasing when misunderstood, and knowing how to use verbal and
nonverbal signals to regulate interaction.
4. Difficulties understanding what is not explicitly stated (e.g., making inferences) and
nonliteral or ambiguous meanings of language (e.g., idioms, humor, metaphors, multiple
meanings that depend on the context for interpretation).

47. Social (Pragmatic) Communication Disorder
B. The deficits result in functional limitations in effective communication, social
participation, social relationships, academic achievement, or occupational
performance, individually or in combination.
C. The onset of the symptoms is in the early developmental period (but deficits
may not become fully manifest until social communication demands exceed
limited capacities).
D. The symptoms are not attributable to another medical or neurological
condition or to low abilities in the domains or word structure and grammar, and
are not better explained by autism spectrum disorder, intellectual disability
(intellectual developmental disorder), global developmental delay, or another
mental disorder.

48. ICD-10: F84: Pervasive Developmental Disorders
F84.0: Childhood autism (< 3 years of age; DSM-IV-TR Autistic Disorder)
• Autistic disorder, Infantile Autism, Infantile Psychosis, Kanner syndrome
F84.1: Atypical autism (> 3 years of age; DSM-IV-TR PDD-NOS)
• Atypical childhood psychosis, Mental retardation with autistic features
F84.2: Rett syndrome
F84.3: Other childhood disintegrative disorder
• Dementia infantilis, Disintegrative psychosis, Heller syndrome
F84.4: Overactive disorder associated with mental retardation and
stereotyped movements
F84.5: Asperger syndrome
• Autistic psychopathy, Schizoid disorder of childhood
F84.8: Other pervasive developmental disorders
F84.9: Pervasive developmental disorder, unspecified

52. Leucovorin for social communication
in young children diagnosed with
ASD
• 26-week long clinical trial
investigating the relationship
between liquid leucovorin and
social communication in
children with ASD.
• Opportunity for neuroimaging
with Magnetoencephalography
(MEG)*
* Not required
• Eligibility:
• Children 2.5-5.5 years old
• Diagnosed with ASD
• Minimum of 10 hours of
behavioral therapy per week
• Not Diagnosed with epilepsy,
genetic syndromes or severe
prematurity
• Known FRAA Status
If interested, please contact Sallie McLees at
smclees@phoenixchildrens.com or (602) 933-0964

53. Leucovorin to develop language
for children diagnosed with ASD
• 26-week long clinical trial
investigating the relationship
between leucovorin calcium and
language impairment in children
with ASD
• Eligibility:
• Children 5.5-12.5 years old
• Diagnosed with ASD
• Moderate Language Delay
• Not Diagnosed with epilepsy,
genetic syndromes or severe
prematurity
• Mental age of at least 18 months
If interested, please contact Sallie McLees at
smclees@phoenixchildrens.com or (602) 933-0964

54. TENS Treatment on anxiety and
sleep in high functioning ASD
One week long study investigating
whether high frequency
transdermal neuromodulation
can decrease anxiety symptoms
and improve sleep in adolescents
and young adults with high
functioning ASD.
Eligibility:
• 10-25 years of age
• Official diagnosis of ASD
• Self reported and observed
complaints of anxiety and/or sleep
disorders
• High functioning – able to do simple
addition, image search and memory
tasks
• Stable medications for at least 3
months
If interested, please contact Amanda Jensen at
ajensen1@pheonixchildrens.com or (602) 933-2979

56. Questions?