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Brett was the first of two children born to middle-class parents both in their

early 40s after difficult pregnancy, with an induced labor at 36 weeks due to
fetal distress. As an infant, Brett was undemanding and relatively placid; he
did not have colic, and motor development proceeded appropriately, but
language development was delayed.

Brett’s parents first became concerned about his development when he was
18 months of age and still not speaking; however, upon questioning, they
noted that, in comparison to other toddlers in his play group, Brett had
seemed less uninterested in social interaction and the social games with
toddlers and adults.

Stranger anxiety became marked at 18 months, much later compared to the


other toddlers in his day care program. Brett would become extremely upset
if his usual day care worker was not present and would tantrum until his
mother took him home.

Brett’s pediatrician initially reassured his parents that he was a “late talker”;
however, when Brett was 24 months old he was referred for developmental
evaluation.

At 24 months, motor skills were age appropriate. His language and social
development, however, was severely delayed, and he was noted to be
resistant to changes in routine and unusually sensitive to aspects of the
inanimate environment. Brett’s play skills were quite limited, and he played
with toys in repetitive and idiosyncratic ways.

His younger sister, now 12 months, was beginning to say a few words, and
the family history was negative for language and developmental disorders.

A comprehensive medical evaluation revealed a normal EEG and CT scan;


genetic screening and chromosome analysis were normal as well.
Brett was diagnosed with autism spectrum disorder, and he was enrolled in a
special education program in which he gradually began to speak.

His speech was extremely literal and characterized by a monotonic voice


quality and an occasional pronoun reversal. Brett often spoke and was able to
make his needs known; however, his language was odd and the other toddlers
did not play with him. Brett pursued mainly solo activities and remained
quite isolated.
By age 5 years, Brett was quite attached to his mother and often became
separation anxious and upset when she went out, exhibiting severe tantrums.
Brett also had developed a number of self-stimulatory behaviors in which he
engaged, such as waving his fingers in front of his eyes. His extreme
sensitivity to change continued over the next few years.

Intelligence testing revealed a full-scale IQ in the average range with relative


weakness in the verbal subtests compared to the performance subtests. In the
4th grade, Brett began to have serious behavioral problems at school and at
home. Brett was unable to complete his class work, would wander around the
classroom, and would begin to tantrum when the teacher insisted that he sit in
his seat. He would sometimes begin screaming so loudly that he had to be
asked to leave the classroom.

He would then become upset and throw all of his books off his desk in a
rage, sometimes inadvertently hitting other students. It took him up to 2
hours to calm down. At home, Brett would fly into a tantrum if anyone
touched his things, and he would become stubborn and belligerent when
asked to do anything that he was not expecting. Brett’s tantrum behavior
continued into middle school, and by the 8th grade, when he was 13 years old,
these behaviors became so severe that the school warned his parents that he
was becoming unmanageable.

Brett was evaluated by a child and adolescent psychiatrist who recommended


a social skills group for him and prescribed risperidone, starting with 0.5 mg
p.o. b.i.d. and titrating up to 1.5 mg p.o. bid.
At that dose, Brett’s tantrums were less frequent and less severe. Brett
seemed calmer in general, and did not become physically out of control
during tantrums.

Brett continued in middle school in a combination of special education


classes and regular classes. Brett’s social skills group was helpful in terms of
teaching him how to approach peers in ways that would lead to less rejection.
Brett had made some acquaintances, and by the time he started high school,
he had acquired two friends who would come to his home and play video
games with him. Brett knew that he was different than the other students, but
he had trouble articulating what was different about him.

Brett continued in high school with a combination of special and regular


education and had plans to attend a community college and live at home for
the first year. (Adapted from a case by Fred Volkmar, M.D.)
DSM Diagnosis of Children/Neurodevelopmental Disorders Background
Another important pair of changes to DSM-5 lies in the realm of childhood
disorders, now called Neurodevelopmental Disorders (APA, 2013a, p. 31).
The first is the change to Autism and related disorders. Using DSM-IV,
patients could be diagnosed with one of four separate disorders: autistic
disorder, Asperger’s disorder, childhood disintegrative disorder, or pervasive
developmental disorder not otherwise specified. Researchers found that these
separate diagnoses were not consistently applied across different clinics and
treatment centers (APA, n.d., DSM-5: TEACHING POINTS FOR
PSYCHOLOGY INSTRUCTORS 10 “Autism Spectrum Disorder”). DSM-5
therefore combined all of these disorders into a single new disorder called
Autism Spectrum Disorder (ASD), defined as persistent deficits in social
communication and interaction associated with restricted, repetitive patterns
of behavior, interests, or activities (Paris, 2013, p. 142). Field trials revealed
that the revised criteria may result in 9-12% of those previously diagnosed in
DSM-IV not meeting the threshold for ASD (Frazier et al., 2012; Huerta,
Bishop, Duncan, Hus, & Lord, 2012), though smaller studies have suggested
that this number could be even higher (Frances, 2012b). Attention deficit
hyperactivity disorder (ADHD) is the second childhood disorder that is
changing criteria, with two key revisions. The first is a later age of onset, with
symptoms now only required to begin by age 12 (APA, 2013a, p. 60) rather
than age 7 in DSM-IV (APA, 2000, p. 92). The second is that, for patients age
17 and older, only five symptoms are required in any subsection (inattention
or hyperactivity/impulsivity) rather than six (APA, 2013a, p. 59). The DSM-5
Task Force claims this change is a special effort to address adults affected by
ADHD to ensure that they are able to get care when needed (APA, n.d.,
“Attention Deficit/Hyperactivity Disorder”). However, these changes may
expand the already worrying overdiagnosis of ADHD (Paris, 2013), with
prevalence rates already ranging from 5-15% in several studies worldwide
(Faraone, Sergeant, Gillberg, & Biederman, 2003; Polanczyk, de Lima, Horta,
Biederman, & Rohde, 2007). Teaching Suggestions Case studies: DSM-IV vs.
DSM-5. To effectively teach the new childhood disorder changes to students,
we suggest that instructors give them short case histories in which each person
meets criteria for a diagnosis in DSM-5 but not DSM-IV (or vice versa).
Because these short cases necessarily have incomplete information, instructors
can discuss with students what additional details they might want from each
client in the real world. In the example below, Gary and Samantha are going
to a party: Gary came late to his own 30th birthday party at Mark’s house
because he forgot about it until the last minute. When he remembered, it took
him another 10 minutes to find his car keys, and then he was halfway to Mark’s
house when he realized he was driving without his wallet. When he got to the
party, Mark tried to rope him into their poker game but Gary was not listening
to what Mark said; then, when Mark repeated his invitation for a third time,
Gary stated that he did not like card games because he had to think too much.
Gary has always been called “spacey” and has had difficulty in school since
the 5th grade. Samantha came to the party because she heard the noise from
next door, although she was not invited. She never had friends her age and did
not appear to seek shared enjoyment or interests with anyone in any activities.
As a kid, she would never play “house” or any other make-believe games. As
an adult, she never seemed to understand when conversations should start or
end. At the party, Sam spent most of her time examining the blades on a ceiling
fan in the bathroom. Note that Gary meets DSM-5, but not DSM-IV, criteria
for ADHD (he has only five, not six symptoms in any category as an adult),
whereas Samantha meets DSM-IV criteria for Autism (or Asperger’s) but not
DSM-5 criteria for ASD. This reversal in prevalence—with ASD diagnoses
decreasing and ADHD diagnoses increasing in DSM-5—can forge an
educational entrance into a discussion about why some diagnostic criteria have
become more stringent and others less so in discussion points. Research is one
possible reason for the change in criteria, although a more pragmatic one may
lie in considering the strongest interest group in DSM-5 and a key sponsor of
APA in general—the pharmaceutical industry (Paris, 2013). In fact, except for
ASD, all the DSM-5 changes loosen diagnosis and threaten to turn the current
diagnostic inflation into diagnostic hyperinflation (Frances, 2012a), possibly
because most DSM-5 disorders other than ASD have medications that are
commonly used as front-line treatments. Use and misuse of psychotropic
medication is perhaps most relevant for ADHD, where stimulant prescriptions
are increasing rapidly (Toh, 2006) despite limited longterm evidence to
indicate its effectiveness (Molina et al., 2009). This issue can also relate back
to Personality Disorders, which were often underdiagnosed using the
multiaxial system (Paris, 2013), possibly because they do not respond well to
medication and are more effectively treated with psychotherapy (Paris, 2008).
Of course, instructors can also discuss the serious caveats of making any
diagnosis based on very limited information (a one paragraph description). As
a corollary to this notion, another option is to have students examine snippets
or excerpts of larger cases at the beginning of the semester to pique their
interest, then reconsider the same but more complete cases later on to see if
their diagnoses changed when given more detailed information. Another theme
that childhood disorders can bring to light is that clinicians typically do not
know whether diagnoses made in childhood are early forms of an adult
disorder, separate disorders, or a bump on the developmental pathway (Paris,
2013). To answer this question, long-term prospective research is required
(much like Molina et al.’s, 2009, 8-year follow-up of a large multisite trial for
ADHD treatments), which is currently rare due to its great expense in terms of
time and money. Students can pair up to design their own longitudinal studies
for any disorder and then present their brief research proposals to the class.
Adam’s Story
Adam’s sixth-grade teachers reported that he could do classroom work, but that he
had a hard time making friends. He seemed to mistrust the motives of classmates
who were sincere and nice to him. Instead, he believed others who laughed and
faked interest in the toy cars and trucks that he brought to school. The teachers
noted that he often cried and rarely spoke in class.Adam, a 12-year-old boy, was
brought in by his mother for psychiatric evaluation. He had temper tantrums that
were causing problems for him at school. She said that school had always been
stressful for Adam and that it had become worse after he entered middle school.

When interviewed one-on-one, Adam mumbled when asked questions about school,
classmates and his family. When asked if he like toy cars, however, Adam lit up. He
pulled out several cars, trucks and airplanes from his backpack. He did not make
good eye contact but talked at length about the vehicles, using their correct names,
such as front-end loader, B-52 and Jaguar.

Adam spoke his first word at age 11 months and began to use short sentences by
age 3. He had always been very focused on trucks, cars and trains. His mother said
that he had always been “very shy” and had never had a best friend. He struggled
with childhood jokes and banter because “he takes things so literally.” Adam’s
mother had always seen this behavior as “a little odd.” She added that this behavior
was like that of Adam’s father, a successful lawyer, who had the same focus in his
interests. Both of them were “sticklers for routine” who “lacked a sense of humor.”

During the exam, Adam was shy and made below-average eye contact. The doctor
diagnosed him with autism spectrum disorder without intellectual impairment. Adam
has trouble interacting with classmates and holding a conversation — both
symptoms of social communication problems. Adam also has fixed interests — he is
interested in cars and trains and little else. Perhaps because his autism spectrum
symptoms were like his father’s behavior, his mother viewed Adam as “a little odd”
but did not seek an evaluation and diagnosis.

Autism spectrum disorder (ASD) is a complex developmental condition that


involves persistent challenges in social interaction, speech and nonverbal
communication, and restricted/repetitive behaviors. The effects of ASD and the
severity of symptoms are different in each person.

ASD is usually first diagnosed in childhood with many of the most-obvious signs
presenting around 2-3 years old, but some children with autism develop normally
until toddlerhood when they stop acquiring or lose previously gained
skills. According to the CDC, one in 59 children is estimated to have autism. Autism
spectrum disorder is also three to four times more common in boys than in girls, and
many girls with ASD exhibit less obvious signs compared to boys. Autism is a
lifelong condition. However, many children diagnosed with ASD go on to live
independent, productive, and fulfilling lives. The information here focuses primarily
on children and adolescents.
Characteristics of Autism Spectrum Disorders
Autism differs from person to person in severity and combinations of symptoms.
There is a great range of abilities and characteristics of children with autism
spectrum disorder — no two children appear or behave the same way. Symptoms
can range from mild to severe and often change over time.

Characteristics of autism spectrum disorder fall into two categories.

o Social interaction and communication problems: including difficulties in normal


back-and-forth conversation, reduced sharing of interests or emotions,
challenges in understanding or responding to social cues such as eye contact
and facial expressions, deficits in developing/maintaining/understanding
relationships, and others.
o Difficulty relating to people, things and events: including trouble making
friends and interacting with people, difficulty reading facial expressions and
not making eye contact.
o Restricted and repetitive patterns of behaviors, interests or activities:

hand-flapping and toe-walking, playing with toys in an uncommon way (such


as lining up cars or flipping objects), speaking in a unique way (such as using
odd patterns or pitches in speaking or “scripting” from favorite shows), having
significant need for a predictable routine or structure, exhibiting intense
interests in activities that are uncommon for a similarly aged child,
experiencing the sensory aspects of the world in an unusual or extreme way
(such as indifference to pain/temperature, excessive smelling/touching of
objects, fascination with lights and movement, being overwhelmed with loud
noises, etc), and others.

Also, while many people with autism have normal intelligence, many others
have mild or significant intellectual delays. Also, those with ASD are at greater risk
for some medical conditions such as sleep problems, seizures and mental illnesses.

f you have concerns that your infant or toddler is not developing normally, it is
important to bring that concern to your primary care provider. The Centers for
Disease Control and Prevention (CDC) have identified possible red flags for autism
spectrum disorder in young children, including:

o Not responding to his/her name by 12 months of age


o Not pointing at objects to show interest by 14 months
o Not playing "pretend" games by 18 months
o Avoiding eye contact or preferring to be alone
o Getting upset by minor changes
o Flapping their hands, rocking their body or spinning in circles
o Having unusual and sometimes intense reations to the way things smell,
taste, feel and/or look
If there is a strong concern that your child is showing possible signs of autism, then a
diagnostic evaluation should be performed. This typically involves an interview and
play-based testing with your child done by a psychologist, developmental-behavioral
pediatrician, child psychiatrist or other providers.

Scientists do not clearly understand what causes autism spectrum disorder. Several
factors probably contribute to autism, including genes a child is born with or
environmental factors. A child is at greater risk of autism if there is a family member
with autism. Research has shown that it is not caused by bad parenting, and it is not
caused by vaccines.

Treatment
While children are not typically cured nor do they outgrow autism, studies have
shown that symptoms can improve with early diagnosis and treatment. There is no
single treatment for autism. Treatments can include intensive skill-building and
teaching educational sessions, known as applied behavior analysis (ABA), and many
more interactive, child-centered versions of behavior treatments. Treatment may also
involve special training and support for parents, speech and language therapy,
occupational therapy and/or social skills training.

Also, some children and adults with ASD have other kinds of psychological
difficulties at some point in their lives, such as anxiety, ADHD, disruptive behaviors
or depression. These difficulties can be treated with therapy or with medication.
There are currently no medications that directly treat the core features of ASD.

In addition to treatment, regular and special education classrooms can be changed


to help students with autism. Many students with autism can function better if the day
is consistent and predictable. It is also helpful if information is presented so the
student can learn by seeing as well as hearing and if students get to play and learn
with nondisabled peers. A federal law — the Individuals with Disabilities Education
Act, or IDEA — requires that special services be available to children identified with
a disability. The services can include early intervention, support for birth through
three years, and special education for children aged three through 21.

Use of complementary and alternative treatments is common among children with


autism, for example, special nutritional supplements and diets. To date, there is little
good scientific evidence that such treatments are effective and sometimes they have
negative consequences; it is important to talk to your doctor before trying any
complementary or alternative treatments.

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