Report of the DSM-V Neurodevelopmental Disorders Work Group
April 2009
Susan Swedo, M.D.
The Neurodevelopmental Disorders Workgroup met in Arlington VA on April 21-22 and discussed the following recommendations for potential changes to DSM-V diagnostic criteria. No final decisions have been made about the changes and feedback will be sought from professional and lay communities before the Workgroup finalizes their recommendations.
PERVASIVE DEVELOPMENTAL DISORDERS (PDD)
1) The Workgroup is considering a change in DSM-V that would replace the Pervasive Developmental Disorder (PDD) category with the title “Autism Spectrum Disorders” (ASD). The change would utilize a single diagnosis for the disorders currently entitled: Autism, PDD-NOS and Asperger disorder. Several factors support making this change:
-
A single spectrum better reflects the pathology and symptoms.
-
Separation of ASD from typical development is reliable and valid, while separation of disorders within the spectrum is variable and inconsistent.
-
Individuals with autism, PDD-NOS or Asperger disorder often are diagnosed by severity, rather than unique, separate criteria defining the three diagnoses.
2) To better reflect the symptomatology and clinical presentation of ASD, changing the three current symptom domains (social deficits, communication deficits and fixated interests/repetitive behaviors) to two (social communication deficits and fixated interests and repetitive behaviors) is also being considered.
Streamlining the current PDD (ASD) criteria to better clarify diagnostic requirements is being examined. The criteria might be presented as relatively brief “bullets” with more extensive examples provided in the accompanying text to better describe symptom presentations at various ages, developmental stages and levels of cognitive functioning. Gender and cultural factors will also be considered to ensure that the ASD diagnosis is made appropriately in diverse patient populations.
3) Symptom severity for ASD could be defined along a continuum that includes normal traits, subclinical symptoms and three different severity levels for the disorder. One possible model:
|
|
Social Communication
|
Fixated Interests and Repetitive Behaviors
|
|
Most severe ASD
|
Minimal or no social communication
|
Nearly constant, complete preoccupation, strongly resists interference with ritual
|
|
Moderately severe ASD
|
Some social communication but interactions noticeably disturbed
|
Frequent and interfering rituals, repetitive behaviors and fixated interests
|
|
Less severe ASD
|
Clear impairments in social communication. Meets all diagnostic criteria including symptom severity greater than threshold
|
Occasional rituals, repetitive behaviors and fixated interests; some interference
|
|
XXXXXXXXXXXX
|
XXXXXXXXXXXXX
|
XXXXXXXXXXXXX
|
|
Subclinical AS Symptoms
|
Has some symptoms from one or both domains but no significant interference or impairment.
|
Odd mannerisms, some excessive preoccupations but distractible, may have ritualized behaviors but they don’t interfere with daily activities
|
|
|
|
|
|
Normal Variation
|
Socially isolated or “awkward”
|
Some ritualized behaviors and preoccupations but these are normal for developmental stage and cause no interference
|
INTELLECTUAL DISABILITIES
DSM-IV uses the term, “Mental retardation” (MR) to describe cognitive deficits. This term is outdated and considered pejorative by many, so the work group is considering a change to the term “Intellectual Disabilities”.
The usefulness of the four current categories (Mild MR, Moderate MR, Severe MR and Profound MR) is being examined, in comparison with a single category of Intellectual Disabilities, with diagnostic specifiers for 1) IQ and 2) Adaptive functioning.
The Workgroup will seek feedback (through RFIs and meetings with stakeholder groups) on these changes in definition, as well as on the specific criteria to be proposed for the intellectual disabilities in DSM-V.