Low Functioning Autism Spectrum...

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Low Functioning

Autism Spectrum Disorder

Walter E. Kaufmann Center for Translational Research

Greenwood Genetic Center Department of Neurology, Boston Children’s Hospital

MIT Simons Center for the Social Brain

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Disclosures

Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest

to disclose

• Consultant to Neuren, Edison, Newron, EryDel, Marinus, Echo Pharmaceuticals and

GW Pharmaceuticals.

• Research support from Ipsen and Eloxx.

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Low Functioning Autism Spectrum Disorder

DSM-5’s Impact on:

Intellectual Disability

&


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DSM-5 & Intellectual Disability:

Potential Decrease in Prevalence

9% decrease

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DSM-5 & Autism Spectrum Disorder:

Selective Disorder, Not Explained by Cognitive Impairment

Autism Spectrum Disorder 51

E. These disturbances are not better explained by intellectual disability (intellectual devel-

opmental disorder) or global developmental delay. Intellectual disability and autism

spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spec-

trum disorder and intellectual disability, social communication should be below that ex-

pected for general developmental level.

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s

disorder, or pervasive developmental disorder not otherwise specified should be given the

diagnosis of autism spectrum disorder. Individuals who have marked deficits in social

communication, but whose symptoms do not otherwise meet criteria for autism spectrum

disorder, should be evaluated for social (pragmatic) communication disorder.

Specify if:

With or without accompanying intellectual impairment

With or without accompanying language impairment

Associated with a known medical or genetic condition or environmental factor

(Coding note: Use additional code to identify the associated medical or genetic condition.)

Associated with another neurodevelopmental, mental, or behavioral disorder

(Coding note: Use additional code[s] to identify the associated neurodevelopmental,

mental, or behavioral disorder[s].)

With catatonia (refer to the criteria for catatonia associated with another mental dis-

order, pp. 119–120, for definition) (Coding note: Use additional code 293.89 [F06.1]

catatonia associated with autism spectrum disorder to indicate the presence of the co-

morbid catatonia.)

Recording ProceduresFor autism spectrum disorder that is associated with a known medical or genetic condition

or environmental factor, or with another neurodevelopmental, mental, or behavioral dis-

order, record autism spectrum disorder associated with (name of condition, disorder, or

factor) (e.g., autism spectrum disorder associated with Rett syndrome). Severity should be

recorded as level of support needed for each of the two psychopathological domains in

Table 2 (e.g., “ requiring very substantial support for deficits in social communication and

requiring substantial support for restricted, repetitive behaviors” ). Specification of “ with

accompanying intellectual impairment” or “ without accompanying intellectual impair-

ment” should be recorded next. Language impairment specification should be recorded

thereafter. If there is accompanying language impairment, the current level of verbal func-

tioning should be recorded (e.g., “ with accompanying language impairment—no intell igi-

ble speech” or “ w ith accompanying language impairment—phrase speech” ). If catatonia is

present, record separately “ catatonia associated with autism spectrum disorder .”

Specif iersThe severity specifiers (see Table 2) may be used to describe succinctly the current symp-

tomatology (which might fall below level 1), with the recognition that severity may vary by

context and fluctuate over time. Severity of social communication diff icul ties and re-

stricted, repetitive behaviors should be separately rated. The descriptive severity categories

should not be used to determine eligibility for and provision of services; these can only be

developed at an individual level and through discussion of personal priorities and targets.

Regarding the specifier “ with or without accompanying intellectual impairment,” un-

derstanding the (often uneven) intellectual profile of a child or adult with autism spectrum

disorder is necessary for interpreting diagnostic features. Separate estimates of verbal and

nonverbal ski l l are necessary (e.g., using untimed nonverbal tests to assess potential

strengths in individuals with limited language).

Autism Spectrum Disorder 51

E. These disturbances are not better explained by intellectual disability (intellectual devel-

opmental disorder) or global developmental delay. Intellectual disability and autism

spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spec-

trum disorder and intellectual disability, social communication should be below that ex-

pected for general developmental level.

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s

disorder, or pervasive developmental disorder not otherwise specified should be given the

diagnosis of autism spectrum disorder. Individuals who have marked deficits in social

communication, but whose symptoms do not otherwise meet criteria for autism spectrum

disorder, should be evaluated for social (pragmatic) communication disorder.

Specify if:

With or without accompanying intellectual impairment

With or without accompanying language impairment

Associated with a known medical or genetic condition or environmental factor

(Coding note: Use additional code to identify the associated medical or genetic condition.)

Associated with another neurodevelopmental, mental, or behavioral disorder

(Coding note: Use additional code[s] to identify the associated neurodevelopmental,

mental, or behavioral disorder[s].)

With catatonia (refer to the criteria for catatonia associated with another mental dis-

order, pp. 119–120, for definition) (Coding note: Use additional code 293.89 [F06.1]

catatonia associated with autism spectrum disorder to indicate the presence of the co-

morbid catatonia.)

Recording ProceduresFor autism spectrum disorder that is associated with a known medical or genetic condition

or environmental factor, or with another neurodevelopmental, mental, or behavioral dis-

order, record autism spectrum disorder associated with (name of condition, disorder, or

factor) (e.g., autism spectrum disorder associated with Rett syndrome). Severity should be

recorded as level of support needed for each of the two psychopathological domains in

Table 2 (e.g., “ requiring very substantial support for deficits in social communication and

requiring substantial support for restricted, repetitive behaviors” ). Specification of “ with

accompanying intellectual impairment” or “ without accompanying intellectual impair-

ment” should be recorded next. Language impairment specification should be recorded

thereafter. If there is accompanying language impairment, the current level of verbal func-

tioning should be recorded (e.g., “ with accompanying language impairment—no intell igi-

ble speech” or “ w ith accompanying language impairment—phrase speech” ). If catatonia is

present, record separately “ catatonia associated with autism spectrum disorder .”

Specif iersThe severity specifiers (see Table 2) may be used to describe succinctly the current symp-

tomatology (which might fall below level 1), with the recognition that severity may vary by

context and fluctuate over time. Severity of social communication diff iculties and re-

stricted, repetitive behaviors should be separately rated. The descriptive severity categories

should not be used to determine eligibility for and provision of services; these can only be

developed at an individual level and through discussion of personal priorities and targets.

Regarding the specifier “ with or without accompanying intellectual impairment,” un-

derstanding the (often uneven) intellectual profile of a child or adult with autism spectrum

disorder is necessary for interpreting diagnostic features. Separate estimates of verbal and

nonverbal ski l l are necessary (e.g., using untimed nonverbal tests to assess potential

strengths in individuals with limited language).

CONFID

ENTIA

LIf Cognitive Impairment is Present, it Should Be Specified

Also problematic features leading mainly to false positive diagnosis: behavioral phenotypical features & psychiatric co-morbidities

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ASD in DSM-5

The Challenge of Demonstrating Selectivity

Is there a problem with diagnosing ASD in ID?

Too Early to Be Definitive but

It Seems to Be the Case

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Is there a problem with ASD Dx in ID (using DSM-5)?

Decreased prevalence of ASD affects less ID

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Is there a problem with ASD Dx in ID?

Insights from Down syndrome, fragile X syndrome & Phelan-

McDermid syndrome

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Insight from fragile X syndrome & Down syndrome

Level of Intellectual Disability is Associated with ASD Dx

Intellectual ability and adaptive behavior profiling: DQ/IQ

0

10

20

30

40

50

60

70

80

% o

f su

bje

cts

<25 25-39 40-54 55-70

Cognitive Level (IQ)

DS+ASD DS+SMD DS Typical

0

10

20

30

40

50

60

70

80

% o

f su

bje

cts

<25 25-39 40-54 55-70 70+

Cognitive Level (IQ)

FXS+ASD FXS Typical

Down Syndrome Fragile X Syndrome

Capone et al. Am J Med Genet 134A:373-380, 2005 Carter et al. Am J Med Genet 144B:87-94, 2007

Kaufmann et al. Am J Med Genet 129A:225-234, 2004 Budimirovic et al. Am J Med Genet 140A:1814-1826, 2006

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Insight from fragile X syndrome

Variable prevalence of ASD in FXS

EMBARGOED – DO NOT COPY – DO NOT DISTRIBUTE CDC Cleared Paper – to be submitted to Pediatrics as part of FXS Supplement

6

relationship between FXS and ASD is complex and evolving, influenced in part by

revised definitions of ASD12

and by a better understanding of behavioral phenotypes

associated with FXS.6 Although variable in degree, a large proportion of individuals with

FXS exhibit poor eye contact, difficulties with peer relationships, social withdrawal,

repetitive behaviors, and need for sameness (i.e., distress at apparently small changes in

daily activities)6,13,14

. Depending on the gold standard research criteria used for the

diagnosis of autism or ASD, studies on males with FXS have reported that 30-54% met

diagnostic criteria for autism by direct assessment15-17

and 46% by parent report18

. In

addition, 30-43% of males met diagnostic criteria for ASD19

or Pervasive Developmental

Disorder-Not Otherwise Specified (PDD-NOS)17

. For females, 16-20% met diagnostic

criteria for autism16

or were assigned by parent report18

18-21

. Several studies have

attempted to delineate unique features of ASD in FXS; their findings show relatively

more prominent social withdrawal, higher levels of anxiety, and less intense simple and

complex repetitive and restricted behaviors as measured by ASD diagnostic

instruments6,22

.

ASD in FXS is associated with greater cognitive and behavioral impairment

ASD is a lifelong disorder, which impacts multiple aspects of the individual’s

functioning. Comparisons between subjects with ASD in FXS (FXS+ASD) and subjects

without ASD in FXS (FXS only) reveal that the former group is more affected in many

cognitive9,19,23

24

and behavioral areas6,7,13,14,22,25

. Examples of areas more problematic in

those with FXS+ASD than with FXS only include less developed language skills,

particularly receptive skills20,23,26,27

; lower non-verbal cognition and IQ scores28,29

; lower

Kaufmann et al. Pediatrics: in press

Even controversial diagnosis Journal of the American Academy of Child &

Adolescent Psychiatry

Volume 49, Issue 9, September 2010, Pages 921–933

New research

Autism in Fragile X Syndrome: A Category Mistake?

Scott S. Hall, Ph.D. , , Amy A. Lightbody, Ph.D., Melissa Hirt, M.A., Ava Rezvani, H.S., Allan L. Reiss,

M.D.

Show more

Autism in Fragile X Syndrome: A Category Mistake? http://www.sciencedirect.com/science/article/pii/S0890856710005265

1 of 4 12/24/16, 1:30 PM

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Insight from fragile X syndrome Psychiatric co-morbidities may influence diagnosis

Hagerman et al. Pediatrics 123:378-390, 2009

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Insight from fragile X syndrome

Decreased prevalence of ASD using DSM-5 (males: 29% SCI, 86% RRB)

Wheeler et al. J Autism Dev Disord 45:816-829, 2015

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Is there a problem with ASD Dx in ID (using DSM-5)?

Insight from Phelan-McDermid syndrome

Over-diagnosis of ASD in PMS (90% SCI, 55% RRB)

Oberman et al. Orphanet J Rare Dis 10:105, 2015 Also Soorya et al. Mol Autism 4:18, 2013

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Insight from Down syndrome

Is the diagnosis of ASD in DS (7-15%) Valid? Cluster Analysis of ABC-C: Likely

Ji et al. J Intellect Disabil Res 55:1064-1077, 2011

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Data from FXS, PMS & DS: several factors may contribute

• Intellectual impairment • Unique behavioral phenotype features

• Psychiatric co-morbidities

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Potential Solutions

Intellectual impairment

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Is there a problem with ASD Dx in ID? Potential Solutions

Intellectual ability and adaptive behavior profiling: DQ/IQ & AB

Kaufmann et al. Am J Med Genet 129A:225-234, 2004 Hernandez et al. Am J Med Genet 149A:1125-1137, 2009

ID is Inherent to ASD but Social rather than Communication skills predict Dx (& severity)

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Potential Solutions Intellectual ability and adaptive behavior profiling: AB

Oberman et al. Orphanet J Rare Dis 10:105, 2015

Relatively Preserved Social Domain: Lower Concern for ASD

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Potential Solutions

Behavioral Phenotype Features

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Potential Solutions Analysis of Behavioral Phenotype Features

• ASD in DS: Impairment in Nonverbal Social Communication (e.g., gestures)

• Non-ASD in DS: Stereotypic Behavior • ASD in FXS: Impairment in (Peer) Relationships • Non-ASD in FXS: Eye Gaze Avoidance, Social Anxiety • ASD in PMS: Abnormal Sensory Reactivity & Nonverbal

Social Communication Impairment • Non-ASD in PMS: Impairment in Social Communication

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Potential Solutions

Psychiatric Co-morbidities

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Potential Solutions Analysis of Psychiatric Co-Morbidities

• ASD in DS: Stereotypic Behavior (SMD) & ADHD-like behaviors

• ASD in FXS: Anxiety- & ADHD-like behaviors • ASD in PMS: Stereotypic Behavior (SMD) & ADHD-like

behaviors

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Potential Solutions

Adapting Diagnostic Instruments

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Is there a problem in ASD with ID?

Potential Solutions

Using ID- & syndrome-adapted instruments: DSM-5’s Novel Features

50 Neurodevelopmental Disorders



Diagnostic Criteria 299.00 (F84.0)

A. Persistent deficits in social communication and social interaction across multiple con-

texts, as manifested by the following, currently or by history (examples are illustrative,

not exhaustive; see text):

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social

approach and failure of normal back-and-forth conversation; to reduced sharing of

interests, emotions, or affect; to failure to initiate or respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging,

for example, from poorly integrated verbal and nonverbal communication; to abnor-

malities in eye contact and body language or deficits in understanding and use of

gestures; to a total lack of facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for ex-

ample, from difficulties adjusting behavior to suit various social contexts; to difficulties

in sharing imaginative play or in making friends; to absence of interest in peers.

Specify current severity:

Severity is based on social communication impairments and restricted, re-

petitive patterns of behavior (seeTable 2).

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at

least two of the following, currently or by history (examples are illustrative, not exhaus-

tive; see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple

motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic

phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of

verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties

with transitions, rigid thinking patterns, greeting rituals, need to take same route or

eat same food every day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g.,

strong attachment to or preoccupation with unusual objects, excessively circum-

scribed or perseverative interests).

4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of

the environment (e.g., apparent indifference to pain/temperature, adverse re-

sponse to specific sounds or textures, excessive smelling or touching of objects,

visual fascination with lights or movement).



petitive patterns of behavior (see Table 2).

C. Symptoms must be present in the early developmental period (but may not become

fully manifest until social demands exceed limited capacities, or may be masked by

learned strategies in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or other im-

portant areas of current functioning.

CONFID

ENTIA

L

50 Neurodevelopmental Disorders



Diagnostic Criteria 299.00 (F84.0)

A. Persistent deficits in social communication and social interaction across multiple con-

texts, as manifested by the following, currently or by history (examples are illustrative,

not exhaustive; see text):

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social

approach and failure of normal back-and-forth conversation; to reduced sharing of

interests, emotions, or affect; to failure to initiate or respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging,

for example, from poorly integrated verbal and nonverbal communication; to abnor-

malities in eye contact and body language or deficits in understanding and use of

gestures; to a total lack of facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for ex-

ample, from difficulties adjusting behavior to suit various social contexts; to difficulties

in sharing imaginative play or in making friends; to absence of interest in peers.



petitive patterns of behavior (seeTable 2).

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at

least two of the following, currently or by history (examples are illustrative, not exhaus-

tive; see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple

motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic

phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of

verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties

with transitions, rigid thinking patterns, greeting rituals, need to take same route or

eat same food every day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g.,

strong attachment to or preoccupation with unusual objects, excessively circum-

scribed or perseverative interests).

4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of

the environment (e.g., apparent indifference to pain/temperature, adverse re-

sponse to specific sounds or textures, excessive smelling or touching of objects,

visual fascination with lights or movement).



petitive patterns of behavior (see Table 2).

C. Symptoms must be present in the early developmental period (but may not become

fully manifest until social demands exceed limited capacities, or may be masked by

learned strategies in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or other im-

portant areas of current functioning.

CONFID

ENTIA

L

SCI

RRB

DSM-5

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Is there a problem in ASD with ID? Potential Solutions

Using ID- & syndrome-adapted instruments: Selected DSM Items

DSM-IV-TR criteria (Combined AUC 0.923, prediction error rate 13.6%)

Pedersen et al. Child Psychiatry Hum Dev: Aug 24, 2016

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Is there a problem in ASD with ID? Potential Solutions

Using ID- & syndrome-adapted instruments: SCQ & SRS in FXS

FXS SCQ Sensitivity 61%, Specificity 70% SRS Sensitivity 97%, Specificity 21%

54 0.2

61 0.272

66 0.333

68 0.359

70 0.386

72 0.41373 0.427 D =

75 0.456

77 0.484

78 0.499 C Y80 0.528

82 0.556

84 0.584

C

D

Y

=

0.00 0.25 0.50 0.75 1.00

1 - Specificity

0.00

0.25

0.50

0.75

1.00

Sen

sit

ivit

y

ROC Curve for SRS Total

Points labeled by: srs_t_tot_calc _cutpt_ _optcorr_ _optdist_ _opty_ _optsesp_

Sens - Spec

0.0

0.2

0.4

0.6

0.8

1.0S

en

s -

Sp

ec

Youden

0.00

0.05

0.10

0.15

0.20

0.25

Valu

e

Distance

0.6

0.7

0.8

0.9

1.0

Dis

tan

ce t

o 0

,1

Correct

0.45

0.50

0.55

0.60

0.65

Co

rrect

rate

50 60 70 80 90 100

SRS T score (calculated) - total

50 60 70 80 90 100

SRS T score (calculated) - total

Tentative SRS Cut-off: 73 (norm: 60)

Idiopathic ASD Correct Dx SCQ (+) 97%, SRS (+) 80% ADOS (+) 96%. ADI-R (+) 98% J Autism Dev Disord 42:257-265, 2012

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Summary

• Too early to be definitive: Slight decrease in ASD Dx with DSM-5 (perhaps also decrease in ID Dx)

• The challenge of demonstrating selectivity: beyond communication and overall intellectual impairment

• Psychiatric co-morbidities & behavioral phenotype can also affect ASD Dx

• Evaluating intellectual ability is essential in ASD Dx • Considering psychiatric co-morbidities & behavioral

phenotype in ASD Dx • Using ID-, syndrome-adapted instruments

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Acknowledgements

• Down Syndrome Team at the Kennedy Krieger Institute (G. Capone, J. Carter)

• Fragile X Team at the Kennedy Krieger Institute (D. Budimirovic, V. Talisa) & FXCRC (E. Berry-Kravis, S. Sherman, S. Kidd, R. Hagerman, D. Hessl, etc.)

• Phelan-McDermid Team at the Greenwood Genetic Center & Boston Children’s Hospital (L. Boccuto, L. Oberman, K. Phelan, S. Sarasua)

• MIT Simons Center colleagues (M. Sur, R. Jaenisch) • DSM-5 NDD Workgroup colleagues

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