2. Heterogeneity in the DSM-5/ DM-ID-2 Autism Spectrum: Linking Biological Traits, Clinical Traits and Treatments Clinical Traits: The Autism Learning Model: Implications for Studying Etiology and Designing Treatment Heterogeneity in the DSM-5/ DM-ID-2 Autism Spectrum: Linking Biological Traits, Clinical Traits and Treatments 32 nd ANNUAL NADD CONFERENCE Nov. 18, 2015 Bryna Siegel, PhD Executive Director, Autism Center of Northern California Professor, Child & Adolescent Psychiatry (Ret.) University of California, San Francisco

3. bryna.siegel@ucsf.edu Atypical Ontogeny versus Typical Development Expected developmental trajectory Influence of neuropathology Development is increasingly constrained by neuropathology as behavioral repertoire becomes more complex.

4. bryna.siegel@ucsf.edu Matrix of Ability and Disability Examples of How Intact Abilities Interact with Impaired Functions to Form Autistic Learning Disabilities (ALDs) Intact Abilities (ALS) Impaired Functions Auditory memoryVisual memory Slow auditory speed =Echolalia with low comprehension (an ALD) Slow auditory speed =Insists on routines (an ALD)

5. bryna.siegel@ucsf.edu De-Constructing Symptoms of ASD ‘ Matrix’ of Ability and Disability: What ‘works’ (abilities) & doesn’t ‘work’ (disabilities) Primary, Secondary & Tertiary Classes of Symptoms Primary Symptoms: Sensory threshold problems (e.g., auditory processing delays) Secondary Symptoms: Successful accommodations arising in ‘Matrix’ (e.g., echolalia, represents good auditory memory, poor auditory processing speed lowering comprehension) Tertiary Symptoms: ‘Matrix’ failures (e.g., poor auditory processing, low comprehension, poor auditory memory, communication frustration and tantrumming)

6. Autistic Learning Disabilities Tertiary/ Failed Accommodations (less dx-specific) Avoiding or sensory-seeking/repetitive sensory behavior Tantrumming/ Avoidance/ Aggression Secondary/ Partial Accommodations (more dx specific) Echoic language and play Lack of affiliative drive/ High Instrumentality Lack of imitation/ lack of non- verbal communication Primary Processes/ Processing Disability in: Perception (e.g., Hypo/-hyper- response to sensory stimuli) Motivation Cognition (receptive/ expressive)

7. Diagnosis Does Not Matter As Much As Symptoms In Studying Etiology (Marco): Ask ‘how did the patient get that way? In-born (primary symptom)? In Studying Treatment (Fancy): Ask is the symptom actually an accommodation? Secondary (partly successful) or tertiary symptom (failed)? The specificity and function of the symptom is more important that the diagnosis/diagnoses it goes with.

8. bryna.siegel@ucsf.edu Considerations in Classifying Symptoms as Primary, Secondary or Tertiary How do alterations in the way a child with ASD perceives, processes, stores, and retrieves information create an altered world view? The differences in perception, processing, storage or retrieval in ASD’s vs controls are the primary disabilities These alterations, by definition will occur in the context of intact and disabled primary processes. The resulting behavioral manifestation can be regarded as an ‘autistic learning disabilities’ (ALDs). We can then study whether specific symptoms/ ALDs point to specific treatments?

9. bryna.siegel@ucsf.edu The ALD/ALS Approach: A New Heuristic ALD = ‘Autistic Learning Disabilities’ ALS = ‘Autistic Learning Styles’ The concept of ASDs and ALSs can be used to classify autistic alterations in perception, cognition, information-processing, motivation and expression

10. bryna.siegel@ucsf.edu Perceives The Child with ASD Perceives Differently Sensory Threshold & Modulation Problems: Audition: Covers Ears Appears Deaf Tactile: Clothes Sensitivities Diminished Pain Response Visual: Gaze Avoidance Visual Scrutiny Olfactory: Pica Gags at Smells

11. Processes The Child with ASD Processes Differently bryna.siegel@ucsf.edu Sensory threshold differences = misrepresentation of input Processing speed delays lead to loss of information If what you: Perceive ✚ Process ✚ Retain is incomplete ‘Spongy’ understanding and need for compensations that access transfer of function to ‘fill in blanks’

12. bryna.siegel@ucsf.edu Stores The Child with ASD Stores Differently ‘Constructive’ memory borrows from more fully represented data sources (e.g., visual v auditory) Retention is better if comprehension is better (problems in retention improved by better self-accommodation e.g., visual) Example problem this can cause: Child mainstreamed above development level at risk for ‘spongy’ knowledge (e.g., rote memorization, no generalization of content)

13. bryna.siegel@ucsf.edu Autistic Learning Disabilities: How Social Deficits Affect Learning Lack of socio-emotional reciprocity= Lack of desire to please others Low response to social reinforcers Lack of awareness of others= Motive to please self is foremost Instrumental learning style Lack of social imitation= Low “incidental” learning via copying others No drive to follow group norms Why Should I Care??

14. bryna.siegel@ucsf.edu Autistic Learning Disabilities: How Non-Verbal Communication Deficits Affect Learning Low comprehension of facial/ vocal cues including: Smiles, frowns, facial expressions (guilt, shame, fear) Tone of voice to mark emotion/ meaning of words Low comprehension gestures/ no theory of mind: No gaze toward topic of conversation No point to initiate joint attention to topic of interest Knowledge base gets more ‘spongy.’

15. bryna.siegel@ucsf.edu Autistic Learning Disabilities: How Verbal Communication Deficits Affect Learning Receptive Language Signal : noise problem for language ‘signal’ Language processing with poor ‘parsing’ (end/ start of words) Overly ‘visual’ (e.g., mainly nouns) leads to partial comprehension Expressive Language Without ‘theory of mind’, no drive to ‘share’ ideas Low social drive= no expression w/o instrumental motive Oral-motor apraxia synergistic w/ low expressive drive

16. bryna.siegel@ucsf.edu Autistic Learning Disabilities: How Play and Exploration Deficits Affect Learning Lack of imagination in play= No assimilation of experience via play (‘small world’/ re-presentational play) No symbolic actions linking words to abstract thinking Stereotyped and repetitive interests= Averse to novelty/ low curiosity Limited learning through exploration Repetitive interests = mental ‘down time’

17. bryna.siegel@ucsf.edu Autistic Learning Styles Defined Autistic learning styles are intact abilities automatically used to compensate for impaired abilities By looking for autistic learning styles, we discover what works and can make more use of those intact abilities (improving on success)

18. bryna.siegel@ucsf.edu Memory Individual Differences in Compensatory Abilities: Autistic Learning Styles (ALSs) Related to Memory Verbal Intelligence-Related Good Auditory Memory without ‘Parsing’ (Memorizes songs, videos or books without understanding full meaning) Performance Intelligence-Related Good Procedural Memory (Prefers Routines) (Anticipates exact events leading to desired outcomes)

19. bryna.siegel@ucsf.edu Motivation Individual Differences in Compensatory Strengths: Autistic Learning Styles (ALSs) Related to Motivation Verbal Intelligence-Related Better use of language when requesting than commenting Performance Intelligence-Related Good visual-motor-spatial abilities without need for language (Does puzzles backward or upside down, draws from ‘photographic’ memory)

20. The Case for De-Emphasis of Diagnosis The Autistic Learning Model was developed to have a nomenclature more useful to etiological and treatment research that a diagnosis alone DSM-type diagnostic categories can serve as a ‘first cut’ for a research sample, or for therapy-eligibility DM-ID does a better job for neurodevelopmental disorders as it considers how ID modifies symptom presentation However, ID is not uniform, and symptom expression will vary by domain

21. The DSM-5 ASD Diagnostic Issues When is new diagnostic nomenclature needed? Are there implications of changes in DSM-5 for clinical care? Are there the implications of changes in DSM-5 for research? If not, why did we need a new DSM? What are (some of) the politics of DSM-5 ASDs?

22. Do We Need New Diagnostic Criteria for ASDs? Stated purpose of a revision to a DSM is to incorporate new research on nosology For Research: Diagnostic Criteria Should 1)Map to etiology: Genetics/ Neuroimaging/Neurochemistry 2)Predict differential treatment responses

23. What there should be to support any new diagnostic nomenclature: RESEARCH:  uniformity of population = more readily ascertained samples (E.g.: Few criteria =easier to recognize syndrome)  assurance of comparable samples= generalizability of research findings on the syndrome

24. What there should be to support any new diagnostic nomenclature: CLINICAL: If it will improve access to services If it will short-list beneficial treatments (E.g., Fewer sx to dx, fewer sx to target) If it will  Sp of traits so it is easy to know what works for what

25. Are DSM-5 ASD criteria built to these specs? No ASDs remain heterogeneous, while gene functions and brain regions are increasingly appreciated for specificity Is this a tug-of-war between the ‘lumpers’ (DSM-5: fewer ASDs) and splitters (DSM-IV: more criteria, more kinds of ASDs?)

26. Diagnostic Shifting from DSM-IV to DSM-5 ASDs DSM-IV Asperger’s disorder in Ss w/o RRBs excluded from ASD, DSM-IV Ss w/ ADHD & ‘autistic-features, now may be ASD as primary dx DSM-IV Ss w/ PDD,NOS w/o RRB: Now SCD & ‘off spectrum’ Slightly different cases are not ASDs… Slightly different cases are ASD…

27. Effect of DSM-5 for Ongoing Research: A Logistical Nightmare How interpretable will findings made in last 20 years be--going forward? Research: Algorithms to map DSM-IV  DSM- 5? What about AGRE, IAN, ATN and other databases? How does DSM-5 ASD map to ICD-10/ 11 Autism Spectrum classifications?

28. How Did We Get Here? ASD-5 & the Politics of Autism-I History of this problem: DSM-III  DSM-III-R databases showed 35%  as fn. of new defn. (Siegel & Spitzer, 1990). DSM-IV: Further ’unexplained’ increases… Is more of a diagnosis ‘good’ for business?

29. How Did We Get Here? ASD-5 & the Politics of Autism-II  in ASD most readily accounted for by APA’s own more broadly applicable criteria Also- Addition of Aspergers Also Flip of ID Ratio:  ‘Old’ ID ratio—70:30  30:70

30. The Politics of ASD Incidence March 2013 (just before DSM-5), CDC says ASDs now 1:55; didn’t ‘fly’, now 1:68 is most accepted #.. Prevalence versus Incidence Studies… The more suspected cases of DD, the more often ASD is in the differential as incidence increases. AAP standards for screening at 18 & 24 m. when Sp is low, but fans the flames Do we have enough ‘Autism Awareness’ yet?

31. Back to the Future?: Research Diagnostic Criteria (RDC) Late 1970s-early 1980s: Concept of RDC as more reliable than clinical diagnostics (per DSM-III). Do researchers now need their ‘own’ RDC criteria more useful for etiologic and prognostic investigations?

32. Arguments in Favor of RDC for Neurodevelopmental Disorders No single criterion for any neurodevelopmental disorder is unique to that disorder; so: How about a taxonomy by ‘family’? Social, Linguistics, Cognitive, Sensory, Motor… With ‘genus’’ level specificity of symptoms: Linguistics> Receptive Language And ‘species’ level resolution: Receptive Language > Auditory Processing Speed

33. Limits to DSM-5 If ASD-5 is not likely to help research, And not likely to help better understand response to interventions, How about a clinically descriptive taxonomy that reflects ‘behavioral’ endophenotypes— small enough observable, clinically well- characterized units--that can link to etiologies, and can be studied in the context of treatment responses…

34. Overlapping disorders? ASDs SPDsIDs Next two presentations will help you decide which is more helpful taxonomy:

35. Next two presentations will help you decide which is a more helpful taxonomy: Clusters of ‘primary’ disabilities? ASDs SensorySocial Communication & Cognition Play & Exploration