DSM-5 under-identifies PDDNOS: Diagnostic agreement between the DSM-5, DSM-IV,and Checklist for Autism Spectrum Disorder

Agreement between the DSM-5, DSM-IV, and Checklist for Autism Spectrum Disorder was assessed in 125 children with autism spectrum disorder (ASD), which included high and low functioning autism (HFA and LFA) and pervasive developmental disorder not otherwise specified (PDDNOS), and children with other clinical disorders (e.g., ADHD, mental retardation, and oppositional-defiant disorder). Diagnostic specificity (true negatives) was 100% for the DSM-5 and 97% for the DSM-IV. Sensitivity (true positives) was high for LFA and HFA (DSM-5 98%, DSM-IV 100%), but only 27% of children with PDDNOS were identified by the DSM-5 as having ASD. The unidentified children had significant autism symptoms on an autism severity measure compared to controls. Overall, children with ASD identified by the DSM-5 increased from 75% to 91% when one less symptom was required for an ASD diagnosis, with only a slight change in specificity (97%), similar to previously published research. Diagnostic agreement between the DSM-5 and DSM-IV for the entire sample increased from 86% to 94% when one less DSM-5 symptom was required. Therefore, under-identification of ASD and low agreement between the DSM-5 and other measures may be resolved if one less symptom is required for an ASD diagnosis.     

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.     

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.     

DSM-5 Autism Spectrum Disorder: In search of essential behaviours for diagnosis

The objective of this study was to identify a set of ‘essential’ behaviours sufficient for diagnosis of DSM-5 Autism Spectrum Disorder (ASD). Highly discriminating, ‘essential’ behaviours were identified from the published DSM-5 algorithm developed for the Diagnostic Interview for Social and Communication Disorders (DISCO). Study 1 identified a reduced item set (48 items) with good predictive validity (as measured using receiver operating characteristic curves) that represented all symptom sub-domains described in the DSM-5 ASD criteria but lacked sensitivity for individuals with higher ability. An adjusted essential item set (54 items; Study 2) had good sensitivity when applied to individuals with higher ability and performance was comparable to the published full DISCO DSM-5 algorithm. Investigation at the item level revealed that the most highly discriminating items predominantly measured social-communication behaviours. This work represents a first attempt to derive a reduced set of behaviours for DSM-5 directly from an existing standardised ASD developmental history interview and has implications for the use of DSM-5 criteria for clinical and research practice.     

Brief Report: An Exploratory Study Comparing Diagnostic Outcomes for Autism Spectrum Disorders Under DSM-IV-TR with the Proposed DSM-5 Revision

The proposed revision for Autism spectrum disorders (ASDs) in the Diagnostic and Statistical Manual of Mental Disorders--Fifth Edition (DSM-5) represents a shift from the Diagnostic and Statistical Manual of Mental Disorders--Fourth Edition, Text Revision (DSM-IV-TR). As the proposed DSM-5 criteria require a higher minimum number of symptoms to be present compared to DSM-IV-TR, there have been some concerns about the impact that this will have on diagnostic outcomes. Therefore, the current study aimed to compare diagnostic outcomes using both DSM-IV-TR and DSM-5 criteria for 132 children. Of the 111 participants who received an ASD diagnosis under DSM-IV-TR, 26 did not meet DSM-5 criteria. The majority of these had received a DSM-IV-TR PDD-NOS diagnosis. Implications of the results and the proposed DSM-5 changes to the ASD criteria are discussed.     

Challenging behaviors in toddlers diagnosed with autism spectrum disorders with the DSM-IV-TR and the proposed DSM-5 criteria

With publication of the DSM-5 slated for May 2013, it has been predicted that the new diagnostic criteria will cause a decrease in the prevalence of autism spectrum disorders (ASDs), seriously impacting children no longer meeting criteria for the disorder. A majority of individuals with ASD have behavior problems which are not considered core features of the disorder but are significantly impairing and often the focus of intervention. The aim of the current study was to investigate types of challenging behaviors in toddlers who may no longer meet diagnostic criteria for ASD using a psychometrically sound measure, the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT) – Part 3. The study included 3339 toddlers, 501 who will retain ASD diagnosis according to the DSM-5; 439 who will no longer meet criteria, and a comparison group of 2399 toddlers referred for evaluation due to atypical development. Though toddlers diagnosed under the DSM-5 exhibited the most challenging behaviors, those who did not meet DSM-5 criteria exhibited significantly more challenging behaviors than the atypically developing toddlers. The effect of the changes in ASD diagnostic criteria on access to early behavioral interventions warrants careful consideration as the new DSM-5 criteria are adopted.     

DSM-5 criteria for autism spectrum disorder maximizes diagnostic sensitivity and specificity in preschool children

Purpose

The criteria for autism spectrum disorder (ASD) were revised in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The objective of this study was to compare the sensitivity and specificity of DSM-IV-Text Revision (DSM-IV-TR) and DSM-5 definitions of ASD in a community-based sample of preschool children.

Methods

Children between 2 and 5 years of age were enrolled in the Study to Explore Early Development-Phase 2 (SEED2) and received a comprehensive developmental evaluation. The clinician(s) who evaluated the child completed two diagnostic checklists that indicated the presence and severity of DSM-IV-TR and DSM-5 criteria. Definitions for DSM-5 ASD, DSM-IV-TR autistic disorder, and DSM-IV-TR Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) were created from the diagnostic checklists.

Results

773 children met SEED2 criteria for ASD and 288 met criteria for another developmental disorder (DD). Agreement between DSM-5 and DSM-IV-TR definitions of ASD were good for autistic disorder (0.78) and moderate for PDD-NOS (0.57 and 0.59). Children who met DSM-IV-TR autistic disorder but not DSM-5 ASD (n = 71) were more likely to have mild ASD symptoms, or symptoms accounted for by another disorder. Children who met PDD-NOS but not DSM-5 ASD (n = 66), or vice versa (n = 120) were less likely to have intellectual disability and more likely to be female. Sensitivity and specificity were best balanced with DSM-5 ASD criteria (0.95 and 0.78, respectively).

Conclusions

The DSM-5 definition of ASD maximizes diagnostic sensitivity and specificity in the SEED2 sample. These findings support the DSM-5 conceptualization of ASD in preschool children.

     

Comorbid psychopathology rates in children diagnosed with autism spectrum disorders according to the DSM-IV-TR and the proposed DSM-5

Abstract

Objective: To investigate differences in comorbid psychopathology rates between individuals who meet criteria of Autism Spectrum Disorders (ASDs) according to DSM-5 or the DSM-IV-TR.

Methods: Comorbid psychopathology was measured using the Autism Spectrum Disorders- Comorbid for Children. 424 individuals between the ages of 2 and 18 years of age; including children who met criteria for an ASD according to the DSM-5, the DSM-IV-TR only, and a control group that did not meet either set of criteria.

Results: Of the ASD participants, 36% would no longer meet criteria according to proposed DSM-5. Comorbidity rates for the ASD groups were significantly different from the control group; however, ASD groups were not significantly different in terms of total comorbid psychopathology.

Conclusion: The results elucidate the need for further research regarding services and treatments for those individuals that will no longer meet criteria for an ASD but still have significant rates of comorbid psychopathology.     

Comparing challenging behavior in children diagnosed with autism spectrum disorders according to the DSM-IV-TR and the proposed DSM-5

Objective: The aim of the current study is to investigate challenging behavior in children who may no longer meet criteria for an autism spectrum disorder (ASD) diagnosis according to the proposed fifth edition of the Diagnostic and Statistical Manual (DSM-5).

Method: Children and adolescents (n?=?459) were separated into three groups including those who met criteria for ASD according to the DSM-5 criteria (n?=?219); those who will no longer qualify for an ASD diagnosis according to the DSM-5 but met criteria according to the DSM-IV-TR (n?=?109); and a control group (n?=?131). Scores on the Autism Spectrum Disorders – Problem Behaviors for Children (ASD-PB-C) were compared among groups.

Results: The DSM-5 captured a slightly more impaired population in terms of problem behavior.

Conclusion: Implications regarding access to treatment for those no longer meeting criteria need to be taken into consideration in the coming months.     

Comparison of ICD-10R, DSM-IV-TR and DSM-5 in an Adult Autism Spectrum Disorder Diagnostic Clinic

An Autism Spectrum Disorder (ASD) diagnosis is often used to access services. We investigated whether ASD diagnostic outcome varied when DSM-5 was used compared to ICD-10R and DSM-IV-TR in a clinical sample of 150 intellectually able adults. Of those diagnosed with an ASD using ICD-10R, 56 % met DSM-5 ASD criteria. A further 19 % met DSM-5 (draft) criteria for Social Communication Disorder. Of those diagnosed with Autistic Disorder/Asperger Syndrome on DSM-IV-TR, 78 % met DSM-5 ASD criteria. Sensitivity of DSM-5 was significantly increased by reducing the number of criteria required for a DSM-5 diagnosis, or by rating ‘uncertain’ criteria as ‘present’, without sacrificing specificity. Reduced rates of ASD diagnosis may mean some ASD individuals will be unable to access clinical services.     

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.     

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.     

Brief Report: Concurrent Validity of Autism Symptom Severity Measures

The autism spectrum disorder (ASD) diagnostic classifications, according to the DSM-5, include a severity rating. Several screening and/or diagnostic measures, such as the autism diagnostic and observation schedule (ADOS), Childhood Autism Rating Scale (CARS) and social responsiveness scale (SRS) (teacher and parent versions), include an assessment of symptom severity. The purpose of this study was to examine whether symptom severity and/or diagnostic status of preschool-aged children with ASD (N = 201) were similarly categorized on these measures. For half of the sample, children were similarly classified across the four measures, and scores on most measures were correlated, with the exception of the ADOS and SRS-P. While the ADOS, CARS, and SRS are reliable and valid measures, there is some disagreement between measures with regard to child classification and the categorization of autism symptom severity.     

Evaluation of retinal nerve fiber layer thickness in children with autism spectrum disorders

BackgroundThe study compared retinal nerve fiber layer (RNFL) thickness, macular thickness, and macular volume of children with autism spectrum disorder (ASD) to those of healthy control group and correlated the RNFL thickness with symptom severity in children with ASD.MethodForty children between the ages of 7 and 12 with normal intelligence levels and who were diagnosed with ASD as per DSM-5 were included in the ASD group. The control group consisted of healthy children, who were matched with subjects in the ASD group in terms of age and gender. The Autism Behavior Checklist (ABC) and Childhood Autism Rating Scale (CARS) were used to evaluate the severity of the disease in the cases diagnosed with ASD. The RNFL, macular thickness, and macular volume of all participants were measured optical coherence tomography (OCT).ResultsThe temporal, temporal superior, nasal superior, temporal inferior, and global RNFL thicknesses were significantly lower in the ASD group than in the control group. There was no correlation between the RNFL thickness and ASD symptom severity. The macular thickness and volume were not significantly different between the groups.ConclusionOur data suggest that lower RNFL thickness may relate to atypical brain development in the ASD, and this can be measured in the retina.     

Social (pragmatic) communication disorder: a research review of this new DSM-5 diagnostic category

Social (pragmatic) communication disorder (SCD) is a new diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). The purpose of this review is to describe and synthesize the relevant literature from language and autism spectrum disorder (ASD) research relating to pragmatic language impairment and other previously used terms that relate to SCD. The long-standing debate regarding how social communication/pragmatic impairments overlap and/or differ from language impairments, ASD, and other neurodevelopmental disorders is examined. The possible impact of the addition of SCD diagnostic category and directions for future research are also discussed.     

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.     

Sialic acid and anti-ganglioside M1 antibodies are invaluable biomarkers correlated with the severity of autism spectrum disorder

BackgroundAutism spectrum disorders (ASD) are devastating neurodevelopmental disorders that showed global increased prevalence. They are characterized by impairment of social communication and stereotyped patterns.ObjectiveThis study aimed at measuring the levels of total sialic acid (SA) and anti-ganglioside M1 (anti- GM1) IgG antibodies as essential biomarkers in a cohort of children with ASD to identify their diagnostic yield as well as their correlation with the severity of autistic behaviors.MethodsThe demographic characteristics, anthropometric measurements, and clinical data were recorded. The levels of total plasma SA and serum anti-GM1 IgG antibodies levels were measured in 100 children with ASD and 100 healthy controls. The severity of ASD-related symptoms was assessed by using the Childhood Autism Rating Scale (CARS).ResultsChildren with ASD had significantly higher levels of both SA and anti-GM1 antibodies than healthy controls (p < 0.001). SA showed a statistically significant moderate diagnostic performance while anti-GM1 antibody showed a statistically significant high diagnostic in differentiating severe from mild to moderate autism. Moreover, both SA and anti-GM1 antibodies levels were significantly correlated to the severity of ASD symptoms (p < 0.001).ConclusionThe significantly increased levels of SA and anti-GM1 antibodies in children with ASD and their correlation with autism-related symptoms suggest their possible etiopathogenic role in autism as one of the pediatric autoimmune neuropsychiatric disorders. However, further large-scale studies are still needed to explore their possible bidirectional relationship as biomarkers for autism.     

Convergent validity of the Autism Spectrum Disorder-Diagnostic for Children (ASD-DC) and Childhood Autism Rating Scales (CARS)

Previous studies analyzed the reliability as well as sensitivity and specificity of the Autism Spectrum Disorder-Diagnostic for Children (ASD-DC). This study further examines the psychometric properties of the ASD-DC by assessing whether the ASD-DC has convergent validity against a psychometrically sound observational instrument for Autistic Disorder. Thirty-seven children and adolescents, ages 3–14 years old were studied. Spearman's Rho was utilized to assess the convergent validity between the ASD-DC and the Childhood Autism Rating Scale (CARS). The ASD-DC and CARS total scores were compared. Additionally, the ASD-DC nonverbal communication, verbal communication, social relationships, and insistence on sameness/restricted interest factors were compared to the CARS items of nonverbal communication, verbal communication, relating to people, and adaptation to change. All correlation coefficients were statistically significant and ranged from .37 to .68, indicating that the ASD-DC demonstrated convergent validity against the CARS. Percent of correct classification was also computed for the ASD-DC and CARS as compared to diagnosis assigned for research purposes according to a checklist derived from the ICD-10 and DSM-IV criteria for autism spectrum disorders. On the ASD-DC, 76.5% correctly met cutoff for ASD and 95.0% were correctly classified as not meeting cutoff for an ASD. Of those meeting the cutoff on the CARS, 58.8% were correctly classified as having an ASD and 85.0% were correctly classified as not having ASD.     

Differentiating between Autism Spectrum Disorders and Other Developmental Disabilities in Children Who Failed a Screening Instrument for ASD

This study compared behavioral presentation of toddlers with autistic spectrum disorders (ASD) and toddlers with global developmental delay (DD) or developmental language disorder (DLD) who display some characteristics of ASD using the diagnostic algorithm items from the Autism Diagnostic Observation Schedule, Generic (ADOS), the Childhood Autism Rating Scale (CARS), and Modified Checklist for Autism in Toddlers (M-CHAT). To date, 195 children have failed the M-CHAT and have been diagnosed with ASD, DD or DLD. Children with ASD had prominent and consistent impairments in socialization skills, especially joint attention skills and were more impaired in some aspects of communication, play, and sensory processing. Children with ASD and children with DD/DLD shared common features, but certain behavioral markers differentiated the two groups.