DSM-5 Update CIFASD Julie A. Kable, Ph.D. Assistant Professor Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine Atlanta, GA

ICCFASD Diagnostic Issues Work Group DSM-5 Revision Subcommittee (Originated 2010) Mary O'Connor (U. California at Los Angeles) Julie Kable  (Emory University) Heather Carmichael Olson (U. of Washington) Sarah Mattson (San Diego State University) Blair Paley (U. California at Los Angeles) Edward Riley (San Diego State University) Sally Anderson (NIAAA, NIH) Kenneth R. Warren (NIAAA,NIH) Special thanks to Bridget Grant

Why was a DSM-5 Diagnosis needed for individuals with an FASD? There was no specific mental health code that adequately documents the cognitive and mental health impact of PAE Intellectual Deficiency Cognitive impairment, NOS Unspecified emotional and behavioral disturbance ADD-ADHD The existing diagnostic codes (760.71) do not adequately capture their mental health needs) Children with FASD may not respond to treatment regimens developed using the existing codes similarly, which may lead to inappropriate treatments When seeking mental health care (assessments or interventions), providers and families often struggle with obtaining appropriate reimbursement for habilitative care

DSM-5 Released May 2013 Need to advance the science so it is accepted completely as a disorder and receives its own unique code 315.81 Pages 798-801

Classical Criteria for Psychiatric Diagnosis (Blashfield & Draguns, 1976) Predictive validity-refers to the category being able to effectively predict the individual’s responsiveness to different treatments. Coverage-the criteria being able to capture all individuals with the condition Descriptive validity-refers to the homogeneity within the symptom categories but not necessarily across the symptom categories/domains Reliability-see the same child/information and the diagnosis is made consistently by different clinicians Team reports and independently reviewing by clinicians to get an estimate of reliability in making the diagnosis Compare experienced vs non-experienced (related to FASD) mental health professionals in making the diagnosis

Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure Symptoms History of More than Minimal Levels of PAE* Domain: Neurocognitive Impairment Global IQ (IQ < 70) Executive function impairment Learning impairment Memory impairment Visual spatial reasoning impairment Domain: Impairment in Self-regulation Impairment in mood or behavioral regulation Attention deficits Impairment in impulse control Domain: Deficits in Adaptive Functioning Skills Communication deficit Social impairment Daily living skills impairment Motor impairment ND-PAE * >13 drinks per month or more than 2 on one occasion

Latent TRAIT OF DISEASE SEVERITY ND-PAE Disease Severity No Symptoms Extreme Symptoms Individuals with a history of PAE are anticipated to have variability in ND-PAE symptomatology allowing for a comparison of cohesiveness and necessity of each item to identify the latent trait of disorder severity.

Symptom Mapping This involves delineating how to positively endorse symptoms (code yes or no) In a clinical context, symptoms are either present or absent based on history or data available from standardized testing Existing databases can be used to assess the validity of the diagnosis with test results and data serving as symptom indicators Deciding what the threshold is for clinical significance? 2.0 STD Units-probably too restrictive 1.5 STD Units 1.0 STD Units Is the more restrictive criteria for adaptive functioning deficits needed? AF 2 of 4- Need two symptoms with one from social or communication adaptive deficits AF-1- Only need one symptom with no restrictions on which one AF 2 of 4 AF 1 1.0 Cut-off Model 1 Model 3 1.5 Cut-off Model 2 Model 4

DAS IQ KBIT COMPOSITE CBCL Attention Medical Dx or ADHD medications

% Positive Endorseme nt (1.5 SD) % Positive Endorseme nt (1.0 SD) Domain Symptom Specific Measure n % Positive Endorseme nt (1.5 SD) % Positive Endorseme nt (1.0 SD) Neurocognitive Global Intellectual Functioning DAS: GCA 56 21.4 K_BIT Composite 55 18.2 Executive Functioning BRIEF Metacognitive Index 51.8 60.7 Impairment In Learning TEMA SS 25.0 53.6 KEYMATH TOTAL SS 42 19.0 47.6 TERA SS 35.7 48.2 Receiving SPEC Ed 48 68.8 Has An IEP 47 72.3 Repeated a grade 45 31.1 Impairment In Memory WISC_3 Letter Span 16.1 32.1 WISC-3 Spatial Span Total 19.6 33.9 WISC-3 Spatial Span Forward WISC-3 Spatial Span Backwards 30.4 WIII-Auditory Working Memory 5.5 23.6 Impairment In Visual-Spatial Reasoning K-BIT Matrices 41.8 Visual SS from VMI 41.1 57.1 DAS: Nonverbal 28.6 55.4 DAS: Spatial WJIII-Spatial Relations 10.9 25.5 WJIII-Visual Matching 29.1 34.5

Specific Symptom Endorsement Domain Specific Symptom % Positive Endorsement (1.5 SD) % Positive Endorsement (1.0 SD) Neurocognitive Global Intellectual Functioning 26.8 Executive Functioning 51.8 60.7 Impairment In Learning 80.4 87.5 Impairment In Memory 33.9 Impairment In Visual-Spatial Reasoning 64.3 83.9 Self-Regulation Impairment In Mood and Behavioral Regulation 85.7 89.3 Attention Deficit 82.1 92.9 Impairment In Impulse Control 69.6 76.8 Adaptive Functioning Adaptive Communication Deficit 55.4 71.4 Adaptive Social Impairment Adaptive Impairment In Daily Living 48.2 73.2 Adaptive Motor Impairment 53.6

Overall Domain and Diagnostic Endorsement Breadth of coverage is good but not when 1. 5 cut-of used with 2 of 4 AF symptoms Overall Domain and Diagnostic Endorsement % Positive Endorsement (1.5 SD) % Positive Endorsement (1.0 SD) Neurocognitive 1 symptom 92.9 96.4 Self-Regulation 94.6 Adaptive Functioning 83.9 2 of 4 symptom 60.7 85.7 ND-PAE Diagnosis 3 Symptoms (1 AF) 82.1 89.3 3 Symptoms (2 of 4 AF)

IntERNAL Consistency of 12 Symptoms-CronBACH’s ALphA

Table 6. Equality of Group Means between Those Diagnosed or Not Symptom Threshold 1.5 Symptoms (AF1) Test- Statistic Threshold 1.5 Symptoms (AF2 of 4) Test-Statistic Threshold 1.0 Symptoms (AF1) Test- Statistic Threshold 1.0 Symptoms (AF2 of 4) Test-Statistic NI_1 F (1,54)=4.67, p < .035 F (1,54)=10.5, p < .002 F (1,54)=2.5, p < .12 F (1,54)=4.1, p < .049 NI_2 F (1,54)=9.68, p < .003 F (1,54)=6.2, p < .016 F (1,54)=2.1, p < .15 F (1,54)=7.3, p < .009 NI_3 F (1,54)=7.85, p < .007 F (1,54)=1.3, p < .256 F (1,54)=2.7, p < .11 F (1,54)=0.9, p < .345 NI_4 F (1,54)=6.79, p < .012 F (1,54)=11.7, p < .001 F (1,54)=0.9, p < .347 F (1,54)=3.9, p < .054 NI_5 F (1,54)=6.76, p < .012 F (1,54)=9.8, p < .003 F (1,54)=15.9, p < .000 F (1,54)=15.3, p < .000 SR_1 F (1,54)=2.48, p < .121 F (1,54)=13.0, p < .001 SR_2 F (1,54)=9.76, p < .003 F (1,54)=5.1, p < .028 F (1,54)=7.7, p < .008 F (1,54)=3.8, p < .057 SR_3 F (1,54)=0.52, p < .473 F (1,54)=0.35, p < .852 F (1,54)=2.7, p < .104 F (1,54)=2.7, p < .103 AF_1 F (1,54)=11.93, p < .001 F (1,54)=68.9, p < .000 F (1,54)=23.1, p < .000 F (1,54)=8.5, p < .005 AF_2 F (1,54)=20.90, p < .000 F (1,54)=34.0, p < .000 F (1,54)=13.1, p < .001 F (1,54)=47.6, p < .000 AF_3 F (1,54)=7.87, p < .007 F (1,54)=35.5, p < .000 F (1,54)=32.6, p < .000 AF_4 F (1,54)=3.18, p < .080 F (1,54)=4.2, p < .046 F (1,54)=8.7, p < .005

Receiver Operative Curve Area Under the Curve Analysis by Cut-off Values Used on Standardized Measures

Relationship of Sum of Symptoms to Participant Characteristics The sum of symptoms was not different between males and females using both cut-off values but did differ by race with more symptoms reported for African American children when using the 1.0 SD cut-off value. The number of symptoms was not related to the child’s level of dysmorphia, number of custody placements, child protective services involvement, years of education, and household income. The number of symptoms was positively related to the child’s age for both cut-off values (1.5 SD: r=.37, p < .006; 1.0 SD: r=.42, p < .001).

Next STEPS Assess these characteristics in a sample with a greater dispersion of ND-PAE –an exposure sample with PAE (CoFASP sample) Assess the symptoms and diagnostic formulations relative to its ability to differentiate from typical controls and other neurodevelopmental and behavior disorders (CIFASD sample)