DSM 5 Assessment and Coding for Autism Spectrum Disorder

As it relates to the DSM-5, the most important thing to understand about diagnosing Autism is that it’s now “Autism Spectrum Disorder.” This means that Autism (as described in the DSM-IV), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder have been replaced with one umbrella diagnosis: autism spectrum disorder 299.00 (F84.0).

The purpose of this revision in the DSM-5 is to improve diagnostic efficacy, accuracy, and consistency.

A general overview of diagnostic criteria, per the DSM-5, is persistent (i.e., regular) deficits in social communication and social interaction across multiple contexts (criterion A). This can include problems with:

• Social-emotional reciprocity (e.g., back and forth conversation)
• Nonverbal communicative behaviors (e.g., abnormalities in eye contact and body language)
• Developing, maintaining, and understanding social relationships.

Autism spectrum disorder (ASD) also requires:

• Restricted, repetitive patterns of behavior, interests, or activities such as stereotyped or repetitive motor movements
• Ritualized patterns or inflexible adherence to routines
• Highly restricted, fixated interests that are abnormal in intensity or focus
• and/or hyper- or hypo reactivity to sensory input (criterion B).

Other criteria also include that symptoms:

• Must be present in the individual’s early developmental period
• Must cause clinically significant impairment in social, occupational, or other important areas of current functioning
• Are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay (These are criterion C through E).

Severity specifiers are given for social communication impairments (criterion A) and restricted repetitive patterns of behavior (criterion B). Severity for both criterion A and B are listed at three different levels:

• Level 1 – requiring support
• Level 2 – requiring substantial support
• Level 3 – requiring very substantial support.

These would be listed with the severity level indicated as well as for which impairment (e.g., social communication and/or repetitive patterns of behavior). For example, a child who meets the criteria for ASD and needs intense support for deficits in social communication, but only moderate support for restrictive repetitive behaviors, would be diagnosed as:
F84.0 Autism Spectrum Disorder, requiring very substantial support for deficits in social communication and requiring substantial support for restrictive repetitive behaviors.

Other specifiers include with or without accompanying intellectual impairment and/or accompanying language impairment.
Counselors should also specify whether the diagnosis is associated with a known medical or genetic condition or environmental factor (If the diagnosis is associated with a medical/genetic/environmental condition or factor, a separate code should be used to identify the issue). Finally, the specifier “with catatonia” can also be used but the additional code 293.89 (F06.1) catatonia associated with autism spectrum disorder should be used.

The DSM-5 dictates that persons with a well-established DSM-IV-TR diagnosis of autistic disorder, asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of ASD. Though controversial, this effectively and officially does away with the diagnosis of “asperger’s disorder.”

In terms of assessment for ASD, the DSM-5 lists one disorder-specific severity measure for autism and social communication disorders, which is Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders (http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures). This is a two-item “measure” which assesses for severity level. Therefore, if one is looking for a complete diagnostic measure for autism one is are perhaps better off using a standardized assessment such as:

The Autism Diagnostic Interview – Revised (ADI-R)
Lord, C., Rutter, M., & Le Couteur, A. (1994). Autism Diagnostic Interview-Revised: a revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. Journal of autism and developmental disorders, 24(5), 659-685.

The Autism Diagnostic Observation Schedule (ADOS)
Lord, C., Risi, S., Lambrecht, L., Cook Jr, E. H., Leventhal, B. L., DiLavore, P. C., … & Rutter, M. (2000). The Autism Diagnostic Observation Schedule—Generic: A standard measure of social and communication deficits associated with the spectrum of autism. Journal of autism and developmental disorders, 30(3), 205-223.

Childhood Autism Rating Scale, Second edition (CARS2)
Schopler, E., Van Bourgondien, M., Wellman, J., & Love, S. (2010). Childhood Autism Rating Scale—Second edition (CARS2): Manual. Los Angeles: Western Psychological Services.

Austin Mom Shares 4 Tips for Raising an ADHD Child

by Kelly Pfeiffer
My 15 year old son has ADHD. We’ve known this since he was about 4 years old. From daycare through middle school I have received a steady stream of “naughty boy” reports from his backpack.

Here are some excerpts (Daycare “Incident Report”):

— “We were doing a group activity; reading and acting out an action story. Instead of listening to directions and being involved in the activity, Jacob started throwing markers at those involved in it.”
— “When we got to the petting zoo, Jacob did not want to wait until it was his turn to enter the gate. He pushed and shoved and got mad. We only had to wait less than a minute to enter.”
— “He threw a sand toy at another child, hitting him in the ear. When I asked him to sit down, I showed him what he had done. He consistently threw rocks at me and the other child.”

I counted 34 “Good Grief” notes from his kindergarten teacher:

— “Jacob continually demonstrates a great difficulty in following specific directions, requires frequent redirection, and disrupts class. Please discuss these problems with him.”
— “Jacob had a hard day today. He was bouncing all over the room and not following directions.”
— And this one was kind of funny: “He told me that he would be better when he is six.”

His bus driver was constantly writing “Notice of Unsafe Behavior on School Bus” forms for Jacob:

“Jacob was out of control this afternoon. He would not stay seated, was on the floor, standing in the seat, and sitting on the back of the seat. He also touched my breast acting like he was going to hit me. This is the second time he has exhibited this behavior. The first time this happened I ignored it thinking it was an accident.”

He ended up having to be strapped into his seat on the bus for his entire kindergarten year.

I counted 75 notes in all, and those are just the ones I’ve kept. They can all be boiled down to:

• Doesn’t follow school rules
• Doesn’t follow simple direction
• Bothers other students
• Personal space problems
• Out of Control
• Won’t stay seated
• Won’t wait his turn
• Pushing and shoving

Every time I opened one of these notes, my heart would sink from the shame, disappointment, and helplessness I felt. I by no means fault his teachers for giving me the notes. In fact, I would ask them to keep me closely informed. As Jacob got older, I found a few precious teachers and principals that partnered with me to help Jacob. They were godsends to me.

Those years were the hardest of my life. I was working a demanding full-time job, my marriage ended, my son was in constant trouble at school and both he and my daughter blamed me for putting an end to our family unit. The pressure was breaking me.

Please; if my story is familiar to you, I want to urge you to get help for you and your child.”

Here are some things that made all of the difference to us:

1. ADHD Assessments, Occupational Therapy, and Child & Family Therapy

An ADHD assessment is not just a series of tests so that you can put the “ADHD” label on your child. It is these tests that will help you know your child’s strengths and weaknesses. Your ADHD child will most likely be hyperactive with low impulse control and a short attention span. That pretty much defines ADHD! But that is not the entire breadth of their character.

Even so, let’s first look at what an occupational therapist and child & family therapist can do to help the hallmark symptoms of ADHD. Your child is most likely running around like a perpetual motor and can’t sit still. He won’t sit down and join the group and he can’t listen to instruction and rules. In elementary school, when my son showed these behaviors, the punishment was to sit on the sidelines during physical education.

Your therapists will know that this is absolutely counterproductive! These kids need an outlet for all of that energy. Help them find that outlet.

Therapy will also help teach your child the difficult concept of self-control. “I will be good when I’m six,” my son said. He really wanted to be good so badly, he just found it impossible.

Your therapist will give your whole family tips and tricks to help him plug into his ability to monitor his actions. They will also help him understand that even when he fails, he is still loved and respected. And for a child constantly in trouble, this is important.

And for the attention deficit, an occupational therapist has many tricks up their sleeve that will help your child narrow their attention when it is needed. They are methods involving music and sound that have been scientifically proven to help the unfocused brain focus.

So back to how your child is much more than his ADHD hallmark symptoms. Psychological testing will measure many of the other things that make your child who he is. This information will allow you to pull him up by his strengths and give him tools to tackle his other deficits. Let’s remember, we all have strengths and deficits, not just ADHD kids. For example, many of us, especially when children, have a degree of OCD (obsessive compulsive disorder.)

But for an ADHD child, a touch of OCD can turn into perseveration over small details of life that make daily coping difficult for all involved. For example, my son perseverated over many things. A promise to go to McDonalds after shopping would result in being “reminded” 10 different times within the hour that he wants a hamburger, fries and Coke … and do I remember that? A knowledgeable therapist can give ideas to you and your child for how to calm the anxiety that is causing the perseveration.

A deficit in small and large muscle motor skills is also very common among ADHD kids. Occupational therapy can help him write legibly and work his muscles to improve strength and balance. Or maybe your child is highly intelligent but has poor verbal skills. Knowing this about your child will help you support and feed his IQ and help him express himself so that his teachers can appreciate his intelligence, too.

And finally, you as the parent of an ADHD child need help for your exhausted and fragile nerves. I didn’t get that kind of help as I should have. I let my needs go for the sake of the needs of my child. The entire family suffers the consequences this. Look after yourself, mom and dad. Get help from a child & family therapist like those at Thriveworks Counseling, WestLake Hills. Find one that specializes in the issues you and your family are facing so that you all can reach your maximum potential and avoid complete burn-out.

2. Programs in Your Child’s School

In Texas we have a school program called ARD. It stands for Admission, Review, and Dismissal. It’s a type of special education but it is not just for academic help. This wonderful group of people can help your child with behavioral issues that make school difficult for him. They will put forth a plan consisting of specific behaviors that your child will work on to improve over the school year. They will have an advocate for your child that visits his classroom throughout the day to check in on how he’s doing.

The classroom teacher can call his advocate at any time if a problem occurs in class. My son had a wonderful advocate that he came to trust and genuinely like. His advocate would talk to him and help him figure out ways bad behavior and the resulting consequences could have been prevented. They are also experts on classroom modifications that your child will benefit from. For example, taking tests in smaller groups and a special study hour in their curriculum. I strongly recommend getting this kind of help from your child’s school. Everyone will benefit.

3. ADHD Medication

Giving ADHD medication to your child is an emotional topic for many. I respect everyone’s choice in this matter because they know their child best and are the most equipped to make decisions on their behalf. If you are considering ADHD meds, go to the person most qualified to help, a child psychiatrist. My son saw a wonderful child psychiatrist and we had to go through a few different medications to find out what was right for him.

He also helped us both understand ADHD traits and why they are important in a society. Historically, the “tribe” could be facing starvation in a terrible winter, and it was the “ADHD” member of the tribe that would leave the cave and travel miles to hunt for food rather than lay down and accept his fate.

He emphasized that we must not try to eradicate these traits, but manage them for our benefit.”

My decision to use medication for Jacob was not so that I could get some relief from him, as many of the anti-drug people believe. I opted for the medicine so that my son would not have to spend his entire school career being told he was a “naughty boy.” I wanted him to get good feedback from his teachers and friends rather than constant criticism.

And most of all, I wanted him to learn something in school. That is what ADHD meds did for him. Maturity did a great deal for my son. He no longer takes any medication, and he’s doing great.

4. Get to know the positive side of ADHD

Educate yourself on the positive traits that people with ADHD have. As a child, these traits may seem like a detriment. With maturity, the deficits become attributes.

Here’s a small list:

• Inability to focus turns into creativity and flexibility
• Hyperactive turns into high energy
• Hypersensitivity turns into sensitivity to others and attention to detail
• Impulsivity becomes fearlessness and ingenuity

Help for Parents

I hope my experiences with ADHD are helpful to at least one person that reads this article. When I recently opened a counseling center in Austin, Texas, it was these experiences that prompted me to hire Stephanie Arsenault, LPC, and Maria Pasqualetti, Ph.D. Stephanie is an expert in child and family therapy. Maria is an expert in child assessments. Working together with your family and your child, they can do miracles.

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ADHD presents some special challenges, but might it also hold some advantages? Click on this video to watch Psychologist Dr. Jessica Pena make a case for why her ADHD clients may have some unique, and often overlooked, advantages and abilities. If you only want audio, visit our Soundcloud page!

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