Diagnosis of autism likely to decline under DSM-5

WASHINGTON – Children diagnosed with pervasive developmental disorder not otherwise specified probably will not meet the criteria for an autism diagnosis under the DSM-5, according to Lawrence Scahill, Ph.D.

"I don’t think schools are going to rearrange labels, but down the road, children we call PDD-NOS [pervasive developmental disorder not otherwise specified] are going to be harder to fit into the new criteria" when the DSM-5 is published in May, said Dr. Scahill, a pediatrics professor at Emory University and the Marcus Autism Center, both in Atlanta.

For some children repetitive behaviors and language, and social delays, will not be "profound [enough]. [Instead,] maybe they’ll get some of what they need by a diagnosis of ADHD," Dr. Scahill said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

The DSM-5’s autism requirements are more restrictive than those of the DSM-IV. For example, in the new manual, autism, Asperger’s syndrome, and PDD-NOS will be lumped together under a single diagnosis of autism spectrum disorder, which is likely to require, among other things, early onset of social communication and interaction deficits, restricted interests, and repetitive behavior, plus an indication of severity level.

The idea is to make the diagnosis of autism more precise. Under the DSM-IV’s more subjective requirements, clinicians could have valid disagreements about where to slot a child, said Dr. Scahill, who formerly served as director of the Research Unit on Pediatric Psychopharmacology at the Yale Child Study Center, New Haven, Conn.

In addition, "a large amount of genetic research from twin studies supports the idea of a spectrum disorder. [Often,] twin one has full autism and twin two has a pastel version, [especially] in monozygotic twins," he said.

The changes will probably decrease the prevalence of autism if people "are careful in their diagnoses," Dr. Scahill said. Many PDD-NOS children will better fit DSM-5’s new "social communication language disorder." The DSM-5s drafters were "trying to get kids with delayed language out of autism," he noted.

Asperger’s is going away, too, which has caused "a great hue and cry from [the Asperger’s] community. They say things like ‘it’s helped me understand myself’ and feel like they won’t have that explanation [anymore], but I don’t think that many kids with [true] Asperger’s will fail to meet the criteria for autism spectrum disorder. There are people who have been given an Asperger’s diagnosis who might not meet it; they might have been overdiagnosed. I don’t think [the change] is as harmful as some think," he said.

The DSM-5 also will allow patients with autistic disorder to be diagnosed with attention-deficit/hyperactivity disorder (ADHD); the DSM-IV specifies that such a dual diagnosis is not made.

In general, ADHD drugs are less effective in children with autism and more likely to cause side effects, Dr. Scahill said.

"Methylphenidate has small to medium effects. Tolerabilities are okay at conservative doses. Study results are mixed" on whether atomoxetine helps or not, but "I wouldn’t say don’t try it. We need more data on guanfacine." Small studies on clonidine suggest children with autistic disorder "are exquisitely sensitive to its sedative side effects," he said.

"When dealing with parents, be up-front and say, ‘We are looking for some help here, but we are not expecting big effects.’ If we can get some benefit at low and medium doses, we’re going to take the money and run," he said.

Dr. Scahill is a consultant for Biomarin and Roche. He also receives research funding from Pfizer, Roche, and Shire Pharmaceuticals.

WASHINGTON – Children diagnosed with pervasive developmental disorder not otherwise specified probably will not meet the criteria for an autism diagnosis under the DSM-5, according to Lawrence Scahill, Ph.D.

"I don’t think schools are going to rearrange labels, but down the road, children we call PDD-NOS [pervasive developmental disorder not otherwise specified] are going to be harder to fit into the new criteria" when the DSM-5 is published in May, said Dr. Scahill, a pediatrics professor at Emory University and the Marcus Autism Center, both in Atlanta.

For some children repetitive behaviors and language, and social delays, will not be "profound [enough]. [Instead,] maybe they’ll get some of what they need by a diagnosis of ADHD," Dr. Scahill said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

The DSM-5’s autism requirements are more restrictive than those of the DSM-IV. For example, in the new manual, autism, Asperger’s syndrome, and PDD-NOS will be lumped together under a single diagnosis of autism spectrum disorder, which is likely to require, among other things, early onset of social communication and interaction deficits, restricted interests, and repetitive behavior, plus an indication of severity level.

The idea is to make the diagnosis of autism more precise. Under the DSM-IV’s more subjective requirements, clinicians could have valid disagreements about where to slot a child, said Dr. Scahill, who formerly served as director of the Research Unit on Pediatric Psychopharmacology at the Yale Child Study Center, New Haven, Conn.

In addition, "a large amount of genetic research from twin studies supports the idea of a spectrum disorder. [Often,] twin one has full autism and twin two has a pastel version, [especially] in monozygotic twins," he said.

The changes will probably decrease the prevalence of autism if people "are careful in their diagnoses," Dr. Scahill said. Many PDD-NOS children will better fit DSM-5’s new "social communication language disorder." The DSM-5s drafters were "trying to get kids with delayed language out of autism," he noted.

Asperger’s is going away, too, which has caused "a great hue and cry from [the Asperger’s] community. They say things like ‘it’s helped me understand myself’ and feel like they won’t have that explanation [anymore], but I don’t think that many kids with [true] Asperger’s will fail to meet the criteria for autism spectrum disorder. There are people who have been given an Asperger’s diagnosis who might not meet it; they might have been overdiagnosed. I don’t think [the change] is as harmful as some think," he said.

The DSM-5 also will allow patients with autistic disorder to be diagnosed with attention-deficit/hyperactivity disorder (ADHD); the DSM-IV specifies that such a dual diagnosis is not made.

In general, ADHD drugs are less effective in children with autism and more likely to cause side effects, Dr. Scahill said.

"Methylphenidate has small to medium effects. Tolerabilities are okay at conservative doses. Study results are mixed" on whether atomoxetine helps or not, but "I wouldn’t say don’t try it. We need more data on guanfacine." Small studies on clonidine suggest children with autistic disorder "are exquisitely sensitive to its sedative side effects," he said.

"When dealing with parents, be up-front and say, ‘We are looking for some help here, but we are not expecting big effects.’ If we can get some benefit at low and medium doses, we’re going to take the money and run," he said.

Dr. Scahill is a consultant for Biomarin and Roche. He also receives research funding from Pfizer, Roche, and Shire Pharmaceuticals.

WASHINGTON – Children diagnosed with pervasive developmental disorder not otherwise specified probably will not meet the criteria for an autism diagnosis under the DSM-5, according to Lawrence Scahill, Ph.D.

"I don’t think schools are going to rearrange labels, but down the road, children we call PDD-NOS [pervasive developmental disorder not otherwise specified] are going to be harder to fit into the new criteria" when the DSM-5 is published in May, said Dr. Scahill, a pediatrics professor at Emory University and the Marcus Autism Center, both in Atlanta.

For some children repetitive behaviors and language, and social delays, will not be "profound [enough]. [Instead,] maybe they’ll get some of what they need by a diagnosis of ADHD," Dr. Scahill said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

The DSM-5’s autism requirements are more restrictive than those of the DSM-IV. For example, in the new manual, autism, Asperger’s syndrome, and PDD-NOS will be lumped together under a single diagnosis of autism spectrum disorder, which is likely to require, among other things, early onset of social communication and interaction deficits, restricted interests, and repetitive behavior, plus an indication of severity level.

The idea is to make the diagnosis of autism more precise. Under the DSM-IV’s more subjective requirements, clinicians could have valid disagreements about where to slot a child, said Dr. Scahill, who formerly served as director of the Research Unit on Pediatric Psychopharmacology at the Yale Child Study Center, New Haven, Conn.

In addition, "a large amount of genetic research from twin studies supports the idea of a spectrum disorder. [Often,] twin one has full autism and twin two has a pastel version, [especially] in monozygotic twins," he said.

The changes will probably decrease the prevalence of autism if people "are careful in their diagnoses," Dr. Scahill said. Many PDD-NOS children will better fit DSM-5’s new "social communication language disorder." The DSM-5s drafters were "trying to get kids with delayed language out of autism," he noted.

Asperger’s is going away, too, which has caused "a great hue and cry from [the Asperger’s] community. They say things like ‘it’s helped me understand myself’ and feel like they won’t have that explanation [anymore], but I don’t think that many kids with [true] Asperger’s will fail to meet the criteria for autism spectrum disorder. There are people who have been given an Asperger’s diagnosis who might not meet it; they might have been overdiagnosed. I don’t think [the change] is as harmful as some think," he said.

The DSM-5 also will allow patients with autistic disorder to be diagnosed with attention-deficit/hyperactivity disorder (ADHD); the DSM-IV specifies that such a dual diagnosis is not made.

In general, ADHD drugs are less effective in children with autism and more likely to cause side effects, Dr. Scahill said.

"Methylphenidate has small to medium effects. Tolerabilities are okay at conservative doses. Study results are mixed" on whether atomoxetine helps or not, but "I wouldn’t say don’t try it. We need more data on guanfacine." Small studies on clonidine suggest children with autistic disorder "are exquisitely sensitive to its sedative side effects," he said.

"When dealing with parents, be up-front and say, ‘We are looking for some help here, but we are not expecting big effects.’ If we can get some benefit at low and medium doses, we’re going to take the money and run," he said.

Dr. Scahill is a consultant for Biomarin and Roche. He also receives research funding from Pfizer, Roche, and Shire Pharmaceuticals.