PSY 3410

AUTISM SPECTRUM DISORDERS &

INTELLECTUAL DISABILITY
Unit 2 – Diagnosis:
Diagnostic Characteristics of ASD
Instructor: Dr. Lauren Moskowitz

Class #2-3 Mon, September 10, & Thurs, September 13, 2018
 DSM-5

¨ Two major characteristics of autism spectrum

disorder are expressed in DSM-5
A. impairments in social communication
and social interaction
B. restricted behavior, interests, & activities

¨ Impairments are present in early childhood and

they limit daily functioning
Means it happened in very early childhood; cannot be diagnosed if
characteristics are expressed starting at age 18
DSM-5 (American Psychiatric Association , 2013)
Diagnostic Characteristics
A. Social Communication Skills
DSM-5: (A) Social-Communication
¨ Socialization and communication deficits are
combined into one set of symptoms
¨ All three symptoms required:

1. Deficits in social-emotional reciprocity

2. Deficits in nonverbal communication during
social interactions
3. Deficits in developing, maintaining, and
understanding relationships (e.g.,
developmentally appropriate peer relationships)
 1. Deficits in
Reciprocal nature tends to be
absent in children with autism

Social Reciprocity
¨ Problems ranging from Children with autism tend to communicate
but not always for social purposes
¤ abnormal social approach
¤ failure of normal back and forth conversation
¤ failure to initiate or respond to social interaction
¤ reduced sharing of interests and emotions
The typical child will
ask a lot of questions Example of
to get information or blowing bubbles;
tell you to look and kids with autism
get you to pay with only watch
attention, share in the bubbles while
experience with them. the average
child will look
Children on the
back between
spectrum do not
you and the Kids with autism
necessarily want to bubbles (back & lack shared (joint)
share their forth) attention; part of
experiences with social reciprocity
anyone, would rather
be alone
 2. Deficits in
Nonverbal Communication
¨ Poorly integrated verbal & nonverbal
communication
¨ Abnormalities in eye contact & body language

¨ Deficits in understanding & using gestures

¨ Lack appropriate facial expressions or tone of

voice (prosody)
¨ Difficulty properly estimating
social distance
 3. Difficulty in
Creating or Maintaining Relationships
¨ Difficulties adjusting behavior to suit various social
contexts
¨ Difficulties in sharing, imaginative
play, or in making friends
¨ Absence of interest in peers
¤ Note: The two previous symptom clusters (problems with social
reciprocity and nonverbal communication) obviously can
contribute to the inability to create new relationships or
maintain current ones
¤ Range – no interest to an interest but an inability or difficulty
High Functioning Autism Aspergers and
Relationships_(360p).mp4
 Levels of Severity for Social
Communication Skills

Mildest level; Most severe

highest level; lowest
functioning functioning
Diagnostic Characteristics
B. Restricted & Repetitive Behaviors
and Interests
 DSM-5

¨ Two major characteristics of autism

spectrum disorder are expressed in DSM-5
A. impairments in social communication
and social interaction
B. restricted behavior, interests, & activities
 B. Restricted and Repetitive Patterns of
Behavior, Interests, or Activities
¨ “The autistic child desires to live in a static world, a world in
which no change is tolerated. The status quo must be
maintained at all cost. Only the child himself may sometimes
take it upon himself to modify existing combinations. But no
one else may do so without arousing unhappiness and
anger. It is remarkable the extent to which children will go
to assure the preservation of sameness” (Kanner, 1973, p. 63)
¨ “Most conspicuous in this respect were his stereotypic
movements. He would suddenly start to beat rhythmically on
his thighs, bang loudly on the table, hit the wall, hit another
person or jump around the room”(Asperger, 1952/1991)
 DSM-V Criteria for ASD:
Restricted Behavior, Interests, or Activities
B. Restricted, repetitive patterns of behavior, interests, or
activities (at least 2): Only need to have 2 out of 4 of these
1. Stereotyped or repetitive motor movements, use of
objects, or speech
overlap

2. Insistence on sameness, inflexible adherence to

routines, or ritualized patterns of verbal or
nonverbal behavior
3. Highly restricted, fixated interests that are abnormal
in intensity or focus
4. Hypo-and-hyper sensory reactivity or interests
Not sensitive enough, or too sensitive
B. Restricted and Repetitive Patterns of
Behavior, Interests, or Activities
1. Speech, motor movements, and/or use of objects
that are overly stereotyped or repetitive
STIMS- self stimulatory behavior
¤ Motor stereotypies, echolalia, repetitive use of
objects, idiosyncratic phrases
Lining up or spinning
wheels on a car are
examples of repetitive
use of objects
 B. Restricted and Repetitive Patterns of
Behavior, Interests, or Activities
2. Extreme resistance to change (“insistence on
sameness”), inflexible following of routines, or
repetitive patterns of verbal or nonverbal behavior
¤ Rigid, rule bound tendency
¤ Preference for sameness (intolerance of change or novelty)
Thrive on predictability and
¤ Difficulty with transitions consistency, but we need to
do a better job preparing
them for changes and need to
learn to accommodate the
fact that stuff happens in life
 B. and Repetitive Patterns of Behavior,
Interests, or Activities
3. Highly restricted, fixated interests that are abnormal
in intensity or focus
¤ Extraordinarily strong fixation or attachment or
preoccupation with unusual objects, excessively circumscribed
or perseverative interests
Positive Fixations
¨ The ability to focus on a topic for long periods of
time can also be positive
¨ Research on the cognitive skills of people with ASD
(usually on the more advanced end of the spectrum)
suggests that they may outperform persons without
ASD on some visiospatial skills, perhaps to maintain
attention on local information
These special interests may make children with ASD very good at their own specialties
 Very restricted eating in children with ASD because maybe they dont like the texture (sensory)

B. Restricted and Repetitive Patterns of

Behavior, Interests, or Activities
4. Hypo-and-hyper sensory reactivity or interests:
Unusual responses to sensory input including the
apparent absence of usual responses, or hyper-
responsiveness to things such as loud noises, textures,
smells, lights, etc., or unusual interest in sensory aspects
of the environment

Sometimes parents bring their child

with autism to the doctor thinking
they are deaf, but really they are
just showing the absence of the
usual response to sound
Levels of Severity for Restricted &
Repetitive Behaviors and Interests

Note: Abnormal motor behaviors & responses to

sensory stimulation seem to diminish with age while
routines & resistance to change don’t
Diagnostic Criteria
Previous criteria DSM-IV criteria
Social Skills: Communication:
•Lack of appropriate •Delay/lack of spoken
nonverbal behaviors: eye language
gaze, facial expression, body
•Impairment in ability to
postures, and gestures to
regulate social interaction
initiate or sustain
•Failure to make peer conversation with others
relationships •Stereotyped & repetitive use
•Lack of joint attention of language or idiosyncratic
(seeking to share enjoyment, language
interests with others) •Lack of varied, spontaneous
•Lack of social or emotional make-believe play
reciprocity Restricted Routines &
Repetitive Behaviors
•Repetitive behaviors
•Motor stereotypies
•Narrow Interests
•Rituals, routines
•Preoccupation with parts
of objects
 The PDD Umbrella

Until May 2013, autism fell under the umbrella of the

Pervasive Developmental Disorders in the
DSM-IV (APA, 2000)
Autistic Disorder (DSM-IV)
(i.e., Classic autism or “Kanner’s autism)

¨ At least two of the social impairment criteria met

¨ At least one of the communication impairment
criteria met
¨ At least one of the restricted & repetitive and
stereotyped patterns of behavior, interests, and
activities criteria is met
¨ Prior to age 3, delay or abnormal functioning in
social interaction, language used as social
communication, or symbolic/imaginative play
 Rett’s Disorder (DSM-IV)
¨ Motor skills deteriorate progressively over time;
social skills develop normally at first, decline (ages
of 1 and 3), and then partially improve
¨ Approximately 1 per 12,000-15,000 live female

births
¨ A genetic disorder - X chromosome
Childhood Disintegrative Disorder (CDD)
(DSM-IV)
¨ Described by Theodore Heller in 1908
¤ Similar to children described by Kanner despite their early
typical development (later onset than Rett’s or AD)
¨ Marked regression in multiple areas following at least
2 years of normal development
¤ Significant loss of previously acquired skills in at least 2
areas of development, including language skills,
social or adaptive skills, bowel or bladder control,
play skills, or motor skills
¤ Deficits in social, communication, & restricted repetitive
and stereotyped patterns of behavior typical of Autistic
Disorder
 Asperger’s Disorder (DSM-IV)
¨ Impaired social relationships and restricted or
unusual behaviors or activities, but without the
language delays associated with Autistic
Disorder
¨ Individuals show few cognitive impairments and
usually have IQ scores within the average range
¤ No significant delays in language development or cognitive
development prior to age 3
¤ Severe and sustained deficits in social interaction
¤ Development of restricted repetitive & stereotyped patterns
of behavior, interests, or activities Adapted from Durand (2014)
 PDD – NOS (DSM-IV)
¨ “Subthreshold” diagnostic category
¨ DSM-IV Diagnostic Criteria: Less strict criteria; only need to have some
impairments (too laxed)
¤ Pervasive impairment in social interaction
¤ Pervasive impairment in communication skills OR presence of
stereotyped patterns of behavior, interests, or activities which
does not meet the criteria for a specific PDD
¤ Presence of impairments that do not meet the criteria for AD
because of late age of onset, atypical symptoms, or subthreshold
¨ Differences from autistic disorder
¤ age of onset
¤ communication deficits less prominent
¤ more heterogeneous
In DSM-IV, we had 3 Core Characteristics:
Difference
between DSM IV
and DSM V
criteria will be
on exam!!!

Reciprocal Social Communication

Interaction

Restricted &
Repetitive Behaviors
Now, in DSM-V, we have 2 Core Characteristics

Social Communication
AND
Social Interaction

Restricted Behavior,
Interests,
& Activities
 Diagnosis of ASD in DSM-V
A. Social/communication deficits (not accounted for by DD)
1. Social-Emotional Reciprocity
Ø e.g., abnormal social approach
Ø e.g., failure of normal back-and-forth conversation
Ø e.g., reduced sharing of interests and emotions
Ø e.g., total lack of initiation of social interaction
2. Nonverbal communication
Ø e.g., poorly integrated verbal & nonverbal communication
Ø e.g., abnormalities in EC & body language
Ø e.g., deficits in understanding & use of nonverbal communication
Ø e.g., total lack of facial expressions or gestures
3. Developing & Maintaining Relationships
Ø e.g., adjusting behavior to suit different social contexts
Ø e.g., difficulties in imaginative play
Ø e.g., difficulties making friends
Ø e.g., no interest in relating to others
B. Restricted, repetitive pattern of behavior, interests, or activities
1. Stereotyped or repetitive speech, motor behaviors, or use of objects
2. Excessive adherence to routines or resistance to change
3. Highly restricted, fixated interests (abnormal in intensity or focus)
4. Hypo-and-hyper sensory reactivity or interests
C. Symptoms must be present in early childhood (but may not manifest)
D. Symptoms must limit and impair everyday functioning
Major Changes from DSM-IV to DSM-V

1) No more subtypes of ASD

n No longer any categories for distinct subtypes of ASD; removed Rett’s
Disorder & collapsed remaining 4 diagnoses into one (ASD)
Ø Autism as one condition that runs along a spectrum
2) Language & social problems combined
§ In the past, there were 3 categories of symptoms à now only 2
3) More symptoms must be met
¤ All 3 social-communication symptoms must be met
¤ Increase from 1 to 2 (or 0 to 2) repetitive & behavioral symptoms
4) Symptoms must be present in early childhood
n Must show symptoms from early childhood, even if symptoms not
recognized until later
n Encourages earlier diagnosis of ASD
4) Three Levels of Severity
¤ Requiring support, substantial support, or very substantial support
¤ Specifiers: presence of accompanying ID and/or language impairment
DSM-5: Why Did They Change the
Criteria?

¨ Better reflection of the state of knowledge about

autism Moved aspergers, Retts, childhood disintegrative disorder & PPDNOS
Went from 3 to 2 main criteria but more symptoms must be met
Added levels of severity

¨Separate diagnoses were not consistently applied

across different clinicians
¨Single umbrella disorder will improve the diagnosis of
ASD without substantially changing the number of
children being diagnosed
¨The spectrum will allow clinicians to account for the
variations in symptoms & behaviors from person to
person
Kathy Lord was chair of DSM-V working group that really felt strongly about removing Aspergers
 Effects of Changes in DSM-V
¨ DSM-V work group: single umbrella disorder will improve
diagnosis of ASD without limiting sensitivity of criteria or
substantially changing # of children being diagnosed
¤ DSM-V field trials indicated no significant changes in prevalence
¨ Lord: new DSM-V criteria led to ~10% reduction in ASD dx
¤ A few recent studies found only 75-80% would retain their DSM-IV
dx; however, small sample sizes and methods of dx limit
interpretability of these findings
¨ Research suggests that most children & adults who have DSM-IV
PDD-NOS or Asperger’s will have enough restricted, repetitive
behaviors by history or currently to meet criteria for ASD in DSM-V
 DSM-5 Asperger’s Controversy
¨ Decision to eliminate Asperger’s in DSM-5 has been Practice Exam Question:
Which of the following is NOT a major change in DSM-IV
Practice exam question:
controversial Echoalia may often be related to:
Lack of language comprehension
to DSM-V?
In the DSM-V the child must no longer show symptoms
from early childhood
¨ Some research suggests that many individuals with
Asperger’s will not (or at least going forward) no longer
have an ASD diagnosis; in some cases SCD diagnosis may
apply, although difficulties are broader than just social
communication
¨ Possible that the constellation of marked social
vulnerability in the face of good language (but poor
communication) skills might represent a different pathway
from autism into serious social disability
Practice exam question:
Practice exam question:
Which of the following is NOT an example of a deficit in nonverbal
Which of the following is NOT an example of a deficit in social
communication?
reciprocity?
The person does not take turns in conversations
Hyper- or hypoactivity to sensory input or unusal interest in sensory
aspects of the environment Volkmar, Reichow, Westphal, & Mandell (2014)