1. Introduction to Autism Spectrum Disorders

2. Centers for Disease Control and Prevention’s Act Early Campaign A child’s growth is more than just physical. From birth to five years, children should reach milestones in how they play, learn, speak and act. A delay in any of these areas could be a sign of a developmental problem, even autism. Baby Steps: Learn the Signs. Act Early.

3. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) On May 18th, the American Psychiatric Association released a new version of the Diagnostic and Statistical Manual of Mental Disorders, DSM-5, the first major revision in 17 years. The DSM is the standard reference that healthcare providers use to diagnose mental and behavioral conditions.

4. DSM-5: The Future of Psychiatric Diagnosis One of the most important changes in the fifth edition of the DSM is the creation of autism spectrum disorder (ASD). This change consolidated diagnoses under one category, Autism Spectrum Disorder, eliminating Asperger’s Disorder, Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS), Autistic Disorder and Childhood Disintegrative Disorder from the manual.

5. Why did it change from the previous version? The DSM is a living document that has changed several times over the last few decades to reflect new research and ongoing psychiatric practice. Researchers found that the separate diagnoses were not consistently applied across different clinics and treatment centers. The revised diagnosis represents a new, more accurate, and medically and scientifically useful way of diagnosing individuals with autism-related disorders.

6. What is Autism Spectrum Disorder? Autism is a complex neurological disorder that typically appears during the first three years of life and lasts throughout a person’s lifetime. The symptoms of people with ASD will fall on a continuum, with some individuals showing mild symptoms and others having much more severe symptoms. This spectrum will allow clinicians to account for the variations in symptoms and behaviors from person to person. Video Glossary: Red Flags

7. Autism Statistics Autism is the fastest-growing developmental disability in the U.S. The latest data from the CDC (2012) estimates that 1 in 88 American children (1 in 54 boys and 1 in 252 girls) has some form of autism spectrum disorder. The new numbers represent a 78% increase in autism over the previous five years. They represent a ten-fold (1,000%) increase in reported prevalence over the last four decades. It occurs in all racial, ethnic, and social groups. It is five times more prevalent in boys than girls.

8. Will DSM-5 change prevalence? The DSM-5 criteria were tested in real-life clinical settings and analysis indicated that there will be no significant changes in the prevalence of the disorder. A study published by Huerta, et al (2012) in the American Journal of Psychiatry found that DSM-5 criteria identified 91 percent of children with clinical DSM-IV PDD diagnoses, suggesting that most children will retain their diagnosis of ASD using the new criteria.

9. Diagnosis REMEMBER the primary reason to obtain diagnosis is to help determine appropriate treatment and education. Diagnosis and a clear understanding of a child’s strengths and weaknesses help you have a better understanding of the child’s needs and more realistic expectations. Video Glossary: Diagnosis

10. Diagnosing Autism There are no medical tests for diagnosing autism. To obtain a diagnosis, you need to go to someone who is qualified, either a medical doctor or a highly specialized psychologist, and experienced in diagnosing children with disorders of communicating, relating and behavior. Children should be evaluated by a multidisciplinary team of professionals including: at least one physician, such as a neurologist, psychiatrist, or developmental pediatrician a psychologist specializing in child development a speech-language pathologist an occupational and/or physical therapist a special educator a social worker

11. Why are Autism Rates Climbing? Changes in diagnostic practices Looking at a population of children in California, researchers from Columbia University reported that approximately 26% of the rise in autism caseload between 1992 and 2005 could be directly attributed to changes in diagnostic criteria, specifically the shift from mental retardation diagnoses to autism diagnoses. This shift stemmed in part from a 1998 directive from the American Psychiatric Association that broadened the definition of autism. Increased awareness In 2010, investigators found that children living in close proximity to another child that had been previously diagnosed with autism had a better chance of being diagnosed with autism themselves. The proposed explanation is information diffusion, or parents talking to and educating other parents about autism resulting in an increased likelihood of their children being diagnosed. It is estimated that 16% of the increase in autism prevalence over time in California was due to social influence and increased awareness.

12. Why are Autism Rates Climbing, cont.? Social factors (Advanced parental age) Researchers at Columbia University found that older mothers and fathers were at increased risk of having a child with autism and estimated that the increase in parental age over time can account for 11% of the increase in prevalence over the same time period. Almost half of the increase is still unexplained Environmental factors and their interactions with genetic susceptibilities are likely contributors to increases in prevalence, but we don’t know. One thing we have learned in the past decade is that there will not be one cause for the increase, but rather multiple causes that contribute to different forms of ASD.

13. What Causes Autism? No known single cause, but it is generally accepted that it is caused by some form of biological or neurological disorder. Risk of recurrence: If parents have a child with some form of autism, there is a 1 in 5 chance (20%) chance that their next child will have autism too (Journal of Pediatrics, 2011). The chance of twins having autism is far higher when twins are identical than when they are fraternal. Having more than one older sibling with autism further increased the chance of diagnosis to 32%. Up to 15% of autism cases have been linked to specific genetic mutations. Various microscopic abnormalities in brain areas such as the cerebellum, limbic system and cerebral cortex Brain scans show differences in brain growth, with a tendency for brains to grow faster that usual in early childhood and then grow more slowly

14. Vaccine Controversy  A controversial hypothesis noted concern over immunization shots (Thimerosal-MMR), even though these vaccines only contained a very small amount of mercury.  Research indicates there is no causal relationship between immunizations and ASDs. In 1999, as a precautionary measure, the US Public Health Service, the American Academy of Pediatrics and vaccine manufacturers agreed that Thimerosal should no longer be used in vaccines for children. Six major studies have found no link and have all largely dismissed the notion that vaccines cause or contribute to autism 1. The Centers for Disease Control and Prevention 2. The Food and Drug Administration 3. The Institute of Medicine 4. The World Health Organization 5. The American Academy of Pediatrics. 6. Journal of Pediatrics (March 2013)

15. Core Deficits of Autism Spectrum Disorder (DSM-IV criteria*) Qualitative impairment in social interaction Qualitative impairments in verbal and non-verbal communication Restricted repetitive and stereotyped patterns of behavior, interests, and activities View Autism Speaks Video Glossary: Developmental MilestonesDevelopmental Milestones

16. Qualitative Impairment in Social Interaction Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction. Failure to develop peer relationships appropriate to developmental level. A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest). Lack of social or emotional reciprocity. View Autism Speaks Video Glossary: Social Interaction: Nonverbal Behaviors, Engaging in Interaction, Sharing Attention, Social ReciprocitySocial Interaction: Nonverbal Behaviors, Engaging in Interaction, Sharing Attention, Social Reciprocity

17. Qualitative Impairments in Verbal and Non-verbal Communication Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gestures or mime). In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others. Estimated that up to 50% of children with autism do not speak. Stereotyped and repetitive use of language or idiosyncratic language. Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level. View Autism Speaks Video Glossary: Communication: Expressive/Receptive Language, Conversation, Repetitive Language and Make Believe PlayCommunication: Expressive/Receptive Language, Conversation, Repetitive Language and Make Believe Play

18. Restricted repetitive and stereotyped patterns of behavior, interests and activities Encompassing preoccupation with one or more stereotyped patterns of interest that is abnormal either in intensity or focus. Apparently inflexible adherence to specific, nonfunctional routines or rituals. Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements). Persistent preoccupation with parts of objects. View Autism Speaks Video Glossary: Repetitive Behaviors and Restrictive Interests: Repetitive Patterns of Interest, Insistence on Sameness, Repetitive Mannerisms and Preoccupations with parts of objects

19. Autism Speaks Launches New Ad Council Campaign – “Maybe” The new “Maybe” PSAs show parents observing the unusual behavior or non-reaction of their child in seemingly ordinary situations. Showing the subtle presence of potential problems in otherwise everyday instances, the PSAs emphasize that these “maybes” are reasons enough for parents to consult their pediatrician or primary care provider for further screening. Autism Speaks Ad Council PSA -- "Maybe" Eye Contact"Maybe" Eye Contact Autism Speaks Ad Council PSA -- "Maybe" Truck"Maybe" Truck

20. What are the changes to the diagnosis of ASD? (DSM-5 criteria) Instead of three domains of autism symptoms (social impairment, language/communication impairment and repetitive/restricted behaviors), two categories will be used: 1. Social communication impairment 2. Restricted interests/repetitive behaviors. Under the DSM-5, diagnosis will require a person to exhibit three deficits in social communication and at least two symptoms in the category of restricted range of activities/repetitive behaviors.

21. What are the changes to the diagnosis of ASD? (cont.)  Under the DSM-5 criteria, individuals with ASD must show symptoms from early childhood, even if those symptoms are not recognized until later.  This criteria change encourages earlier diagnosis of ASD but also allows people whose symptoms may not be fully recognized until social demands exceed their capacity to receive the diagnosis. It is an important change from DSM- IV criteria, which was geared toward identifying school- aged children with autism-related disorders, but not as useful in diagnosing younger children.

22. What are the changes to the diagnosis of ASD? (cont.) Within the second category, a new symptom will be included: hyper- or hypo-reactivity to sensory input or unusual interests in sensory aspects of the environment. In addition to the diagnosis, each person evaluated will also be described in terms of any known genetic cause (e.g. fragile X syndrome, Rett syndrome), level of language and intellectual disability and presence of medical conditions such as seizures, anxiety, depression, and/or gastrointestinal (GI) problems.

23. How will these changes affect diagnosis and support services? Individuals who currently have a diagnosis on the autism spectrum, including those with Asperger syndrome or PDD-NOS, will not lose their ASD diagnosis. No one should be reevaluated or “lose” their diagnosis because of administrative reasons of the DSM-5.

24. DSM-5 Video Series Listen to Dr. Susan E. Swedo (Chair, DSM-5 Neurodevelopmental Disorders Work Group) explain the new organization and features of the DSM-5 and the diagnostic differences between DSM-IV-TR and DSM-5. What are the changes to autism spectrum disorder in DSM-5? What are the changes to autism spectrum disorder in DSM-5? What will be the impact of DSM-5 changes to autism spectrum disorder? What will be the impact of DSM-5 changes to autism spectrum disorder?

25. Social concerns that are red flags for autism Not responsive to other people's facial expressions/feelings Has limited or fleeting eye contact Poor insight as to what other people are thinking; difficulty interpreting facial expressions Inappropriate affect Lack of initiation of activity or social play Absence of social interaction and/or ability to initiate or reciprocate play Is very independent; little interest in others Is in his or her own world; Tunes us out Does not show typical interest in, or play near peers Lack of pretend play; little or no imagination Lack of turn taking

26. Communication concerns that are red flags for autism Appears deaf at times Seems to hear sometimes but not at other times Does not respond to his or her name Doesn’t follow directions Qualitative impairment in nonverbal communication Not pointing at an object to direct another person’s gaze Little use of gestures and facial expressions Lack of visual tracking and gaze monitoring Using an adult's hand as a tool Delay or absence of spoken language Cannot tell me what he or she wants Speech may remain repetitive and non-communicative, and may be marked by echolalia

27. Behavioral concerns that are red flags for autism: Is hyperactive/uncooperative or oppositional Toe walks Has tantrums Has unusual attachments to toys (e.g., always is holding a certain object) Play with toys in a repetitive, nonfunctional manner Unusual stereotypic and/or repetitive movements Unusual reactions, or lack of reaction, to sensory stimuli Developing rigid routines, and difficulty accepting change in the environment or in daily routine