The Nisonger Center

Report
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:
DSM – II:
DSM – III:
DSM – IV:
1952
1968
1980 => DSM–III-R: 1987
1994 => DSM–IV-TR: 2000
DSM – 5: 2013 (12-year process)
Nisonger Center
DSM-5 (APA, 2013)
Development Timeline:
2000-2006:
publication « white papers » various topics related
to mental disorders
2006-2008:
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:
clinical trials, analyses of results, revisions
2012:
last public consultations, final revisions to drafts
2013:
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
Depressive
Disorders disorders are a group of
Neurodevelopmental
…conditions with onset in the developmental
period.
Nisonger Center
DSM-5
Neurodevelopmental
Disorders
Intellectual
Communication
Autism Spectrum
Disabilities
Disorders
Disorder
Attention-Deficit/
Hyperactivity
Disorder
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Specific Learning
Disorder
Other
Motor Disorders
Neurodevelopmental Disorders
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
Nisonger Center
DSM-5
Neurodevelopmental
Disorders
Intellectual
Communication
Autism Spectrum
Disabilities
Disorders
Disorder
Attention-Deficit/
Hyperactivity
Disorder
Nisonger Center
Specific Learning
Disorder
Other
Motor Disorders
Neurodevelopmental Disorders
DSM-5
Neurodevelopmental
Disorders
Intellectual
Communication
Autism Spectrum
Disabilities
Disorders
Disorder
Attention-Deficit/
Hyperactivity
Disorder
Intellectual
Disability
Global
Developmental
Delay
Unspecified
Intellectual
Disability
Nisonger Center
Specific Learning
Disorder
Other
Motor Disorders
Neurodevelop-
mental Disorders
DSM-5
Neurodevelopmental
Disorders
Intellectual
Communication
Autism Spectrum
Disabilities
Disorders
Disorder
Attention-Deficit/
Hyperactivity
Disorder
Intellectual
Disability
Global
Developmental
Delay
Unspecified
Intellectual
Disability
Nisonger Center
Specific Learning
Disorder
Other
Motor Disorders
Neurodevelop-
mental Disorders
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
Nisonger Center
DSM-5
319. Intellectual Disability
(Intellectual Developmental Disorder)
“Note: The diagnostic term Intellectual Disability is the equivalent
term for the ICD-11 diagnosis of 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. 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
journals use the term Intellectual Disability. 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
DSM-5
319. Intellectual Disability
(Intellectual Developmental Disorder)
“Note: The diagnostic term Intellectual Disability is the equivalent
term for the ICD-11 diagnosis of 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.. 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
journals use the term Intellectual Disability. 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 Disability
(Intellectual Developmental Disorder)
“… is a disorder with onset during
“… 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
- APA, 2013, p. 18.“
the developmental period that
includes both intellectual and
adaptive
functioning deficits in conceptual,
social, and practical domains.“
33
1
Nisonger Center
- Schalock et al., 2010, p.
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 intellectual functions … intellectual
functioning is typically measured with individually
administered and psychometrically valid, comprehensive,
culturally appropriate, psychometrically sound tests of
intelligence.
… 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”….
Nisonger Center
Intellectual Disability
Diagnostic Features (p. 37)
Criterion A refers to intellectual functions … intellectual
functioning is typically measured with individually
administered and psychometrically valid, comprehensive,
culturally appropriate, psychometrically sound tests of
intelligence.
… 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 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 that result in failure to
meet developmental and sociocultural standards for
personal independence and social responsibility.
Without ongoing support, the adaptive deficits limit
functioning in one or more activities of daily life, such
as communication,
social participation, and independent living, and
across multiple environments, such as home, school,
work, and recreation.
- DSM-5, p. 33
Nisonger Center
Intellectual Disability
Diagnostic Features (p. 37 & 38)
Criterion B – adaptive functioning involves adaptive reasoning, in
three domains: conceptual, social, and practical. … criterion B is met
when at least ONE domain of adaptive functioning, conceptual, social
or practical is sufficiently impaired that ongoing support is needed….
Adaptive functioning is assessed using both clinical evaluation and
individualized, culturally appropriate, psychometrically sound
measures. 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.
Nisonger Center
Intellectual Disability
Diagnostic Features (p. 37 & 38)
Criterion B – adaptive functioning involves adaptive reasoning, in
three domains: conceptual, social, and practical. … criterion B is met
when at least ONE domain of adaptive functioning, conceptual, social
or practical is sufficiently impaired that ongoing support is needed….
Adaptive functioning is assessed using both clinical evaluation and
individualized, culturally appropriate, psychometrically sound
measures. 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.
Nisonger Center
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.”
Nisonger Center
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
sing 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.”
Nisonger Center
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
SPECIFIERS
The use of specifiers for the neurodevelopmental
disorder diagnoses enriches the clinical description of
the individual’s clinical course and current
symptomatology.
•
•
•
•
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)
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Intellectual Disability
SPECIFIER - CURRENT SEVERITY OF ID:
The severity levels of ID are defined on the basis of
adaptive functioning, and not IQ scores, because it is
adaptive functioning that determines the level of
supports required. Moreover, IQ measures are less
valid in the lower end of the IQ range.
Severity levels of ID: Mild, Moderate, Severe, & Profound.
-
DSM-5, p. 33
Nisonger Center
Intellectual Disability
SEVERITY LEVELS FOR INTELLECTUAL DISABILITY:
Conceptual
Domain
Severity
Social
Domain
Practical
Domain
Mild
Moderate
Severe
Profound
- DSM-5, p. 34-36
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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:
Same:
Same:
???:
Different:
Different:
Name “intellectual disability”
IQ
AB domains
Age of onset
Severity levels
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

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