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Transcript The Nisonger Center

DSM-5: Diagnosing Intellectual Disability

Marc J. Tassé, PhD Nisonger Center AAIDD WEBINAR DSM-5: A Spotlight On Autism Spectrum Disorder and Intellectual Disability December 10, 2013

American Psychiatric Association DSM – I: 1952 DSM – II: 1968 DSM – III: 1980 => DSM–III-R: 1987 DSM – IV: 1994 => DSM–IV-TR: 2000 DSM – 5: 2013 (12-year process)

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DSM-5 (APA, 2013)

Development Timeline: 2000-2006: 2006-2008: publication « white papers » various topics related to mental disorders David J. Kupfer and Darrel A. Regier – chair/co-chair => work groups 2008-2010: review of the research literature, analysis of existing datasets, first drafts of chapters, publication of drafts on www.dsm5.org

2010-2012: 2012: 2013: clinical trials, analyses of results, revisions last public consultations, final revisions to drafts publication of DSM-5 Nisonger Center

DSM-5

DSM-5 CLASSIFICATION Section I (DSM-5 Basics) Section II (Diagnostic Criteria and Codes)

• • • • •

22 mental disorder categories: Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders … Nisonger Center

DSM-5

DSM-5 CLASSIFICATION Section I (DSM-5 Basics) Section II (Diagnostic Criteria and Codes)

• • • • •

22 mental disorder categories: Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Neurodevelopmental disorders are a group of conditions with onset in the developmental period.

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DSM-5

Neurodevelopmental Disorders Intellectual Disabilities Communication Disorders Autism Spectrum Disorder Attention-Deficit/ Hyperactivity Disorder Specific Learning Disorder Motor Disorders Other Neurodevelop mental Disorders Nisonger Center

Neurodevelopmental Disorders

Work Group

• Susan Swedo, M.D., National Institute of Mental Health • *Gillian Baird, M.B., Guy's and St. Thomas' Hospital • *Edwin Cook, M.D., University of Illinois at Chicago • *Francesca Happé, Ph.D., King's College London • James Harris, M.D., Johns Hopkins University • Walter Kaufmann, M.D., Harvard University • Bryan King, M.D., University of Washington • *Catherine Lord, Ph.D., Weill Cornell Medical College • *Joseph Piven, M.D., University of North Carolina, Chapel Hill • *Sally Rogers, Ph.D., University of California, Davis • *Sarah Spence, M.D., Ph.D., Harvard University • *Amy Wetherby, Ph.D., Florida State University • *Harry Wright, M.D., University of South Carolina

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DSM-5

Global Developmental Delay Unspecified Intellectual Disability

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DSM-5

Global Developmental Delay Unspecified Intellectual Disability

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DSM-5

( 319. Intellectual Disability

Intellectual Developmental Disorder

) [ICD-11] “…

is a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains.“

- DSM 5, page 33

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DSM-5

319. Intellectual Disability (Intellectual Developmental Disorder) “Note:

The diagnostic term

Intellectual Disability

term for the ICD-11 diagnosis of is the equivalent

Intellectual Developmental Disorders

. Although the term journals use the term

Intellectual Disability

relationships with other classification systems. Intellectual Disability . Thus, is used throughout this manual, both terms are used in the title to clarify Moreover, a federal statute in the United States (Public Law 111-256, Rosa’s law) replaces the term mental retardation with intellectual disability, and research Intellectual Disability is the term in common use by medical, educational, and other professions, and by the lay public and advocacy groups.”

DSM-5, p. 33 Nisonger Center

DSM-5

319. Intellectual Disability (Intellectual Developmental Disorder) “Note:

The diagnostic term

Intellectual Disability

term for the ICD-11 diagnosis of is the equivalent

Intellectual Developmental Disorders

. Although the term

Intellectual Disability is used

throughout this manual, both terms are used in the title to clarify relationships with other classification systems.

journals use the term Intellectual Disability . Moreover, a federal statute in the United States (Public Law 111-256, Rosa’s law) replaces the term mental retardation with intellectual disability, and research . Thus,

Intellectual Disability

is the term in common use by medical, educational, and other professions, and by the lay public and advocacy groups.”

DSM-5, p. 33 Nisonger Center

ICD-11 (WHO, in preparation)

Intellectual Developmental Disorders

“ Disorders of intellectual development refer to a group of etiologically diverse conditions originating during the developmental period characterized by significantly below average intellectual functioning and adaptive behavior that is approximately two or more standard deviations below the mean (≈<2.3 percentile), as established based on appropriately normed, standardized tests or by comparable clinical indicators when standardized testing is unavailable. …” Nisonger Center

DSM-5 AAIDD

319. Intellectual Disability (Intellectual Developmental Disorder) Intellectual Disability “… is a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains.“

- APA, 2013, p.

“… is characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills. The disability originates before age 18.“

33 - Schalock et al., 2010, p. 1

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DSM-5

319. Intellectual Disability (Intellectual Developmental Disorder) The following three criteria must be met: A. Deficits in intellectual functions , such as reasoning, problem-solving, planning, abstract thinking, judgment, academic learning and learning from experience, and practical understanding confirmed by both clinical assessment and individualized, standardized intelligence testing.

- DSM-5, p. 33 Nisonger Center

Intellectual Disability

Diagnostic Features (p. 37) Criterion A refers to functioning is typically measured with individually administered and psychometrically valid, comprehensive, culturally appropriate, psychometrically sound tests of intelligence. intellectual functions … intellectual … two standard deviations or more below the population mean, including a margin of measurement error (generally + 5 points) … a score of 65 – 75 (70 ± 5).

Factors that may affect test scores include practice effects and the “Flynn effect”….

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Intellectual Disability

Factors that may affect test scores include effects and the “ Flynn effect ”….

practice Nisonger Center

Intellectual Functioning

”IQ test scores are approximations of conceptual functioning but may be insufficient to assess reasoning in real-life situations and mastery of practical tasks. For example, a person with an IQ score above 70 may have such severe adaptive behavior problems in social judgment, social understanding, and other areas of adaptive functioning that the person’s actual functioning is comparable to that of individuals with a lower IQ score. Thus, clinical judgment is needed in interpreting the results of IQ tests.” - DSM-5, p. 37 Nisonger Center

DSM-5

319. Intellectual Disability (Intellectual Developmental Disorder) B. Deficits in adaptive functioning meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning that result in failure to in one or more activities of daily life , such as communication

social participation

across multiple environments, such as home, school, work, and recreation and

independent living

and - DSM-5, p. 33 Nisonger Center

Intellectual Disability

Diagnostic Features (p. 37 & 38) Criterion B – adaptive functioning

three domains: when at least

conceptual

social

involves adaptive reasoning , in , and

practical

. …

criterion B

is met

ONE domain of adaptive functioning, conceptual , social or practical is sufficiently impaired

that ongoing support is needed….

Adaptive functioning is

measures assessed using both clinical evaluation and individualized, culturally appropriate, psychometrically sound

. Standardized measures are used with knowledgeable informants (e.g., parent or other family member, teacher, counselor, care provider) and the individual to the extent possible.

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Intellectual Disability

Diagnostic Features (p. 37 & 38) Criterion B – adaptive functioning

three domains: when at least

conceptual

social

involves adaptive reasoning, in , and

practical

. …

criterion B

is met

ONE domain of adaptive functioning, conceptual, social or practical is sufficiently impaired

that ongoing support is needed….

Adaptive functioning is

measures assessed using both clinical evaluation and individualized, culturally appropriate, psychometrically sound

. Standardized measures are used with knowledgeable informants (e.g., parent or other family member, teacher, counselor, care provider) and the individual to the extent possible.

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Intellectual Disability

Diagnostic Features (p. 37 & 38) Criterion B – adaptive functioning

“

Additional sources of information include educational, developmental, medical, and mental health evaluations. Scores from standardized measures and interview sources must be interpreted using clinical judgment.

” “

Adaptive functioning may be difficult to assess in a controlled setting (e.g., prisons, detention centers); if possible corroborative information reflecting functioning OUTSIDE those settings should be obtained.

”

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Intellectual Disability

Diagnostic Features (p. 37 & 38) Criterion B – adaptive functioning

“

” “

”

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Intellectual Disability

Diagnostic Features (p. 38) Criterion B – adaptive functioning

“

To meet diagnostic criteria for ID, the deficits in adaptive functioning must be directly related to the intellectual impairments described in Criterion A

.”

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DSM-5

319. Intellectual Disability (Intellectual Developmental Disorder)

C. Onset of intellectual and adaptive deficits during the

developmental period

- DSM-5, p. 33

“

Criterion C, onset during the developmental period, refers to recognition that intellectual and adaptive deficits are present during the childhood or adolescence.

”

- DSM-5, p. 38 Nisonger Center

DSM-5

S PECIFIERS The use of specifiers disorder diagnoses enriches the clinical description of the individual’s clinical course and current symptomatology. for the neurodevelopmental

• • • •

age of onset severity level of ID … associated with a medical (e.g., seizure disorder) … etiology: genetic condition (e.g., trisomy 21) or environmental factor (e.g., low birth weight) Nisonger Center

Intellectual Disability

S PECIFIER - C URRENT S EVERITY OF ID: The severity levels of ID are defined on the basis of adaptive functioning, and adaptive functioning that determines the level of supports required not IQ scores . Moreover, IQ measures are less valid in the lower end of the IQ range. , because it is Severity levels of ID: Mild, Moderate, Severe, & Profound.

DSM-5, p. 33

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Intellectual Disability

S EVERITY L EVELS FOR I NTELLECTUAL D ISABILITY : Severity Mild Moderate Severe Profound Conceptual Domain Social Domain Practical Domain - DSM-5, p. 34-36 Nisonger Center

Similarities and Differences

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Intellectual Disability

DSM-5-AAIDD: Similarities and Differences.

Same: Same: Same: Name “intellectual disability” Intelligence => IQ criterion AB domains DSM-5 (p. 40): “ the AAIDD also uses the term intellectual disability with a similar meaning to the term used in this manual.” Nisonger Center

Intellectual Disability

DSM-5-AAIDD: Similarities and Differences.

Same: Same: Same: ???: Name “intellectual disability” IQ “< 2 standard deviations below the mean” AB domains Age of onset Nisonger Center

Intellectual Disability

DSM-5-AAIDD: Similarities and Differences.

Same: Name “intellectual disability” Same: Same: ???: IQ AB domains Age of onset Different: Severity levels Different: Operational definition of “significant deficits” in AB Different: Link AB deficits to IQ Nisonger Center

DSM-5: Diagnosing Autism Spectrum Disorder

Jarrett Barnhill, MD, DFAPA, FAACAP

AAIDD WEBINAR DSM-5: A Spotlight On Autism Spectrum Disorder and Intellectual Disability December 10, 2013