Transcript Julie Kable

DSM-5 UPDATE CIFASD
Julie A. Kable, Ph.D.
Assistant Professor
Department of Psychiatry and Behavioral Sciences,
Emory University School of Medicine
Atlanta, GA
ICCFASD DIAGNOSTIC ISSUES WORK
GROUP DSM-5 REVISION
SUBCOMMITTEE
(ORIGINATED 2010)
 Mary O'Connor (U. California at Los Angeles)
 Julie Kable (Emory University)
 Heather Carmichael Olson (U. of Washington)
 Sarah Mattson (San Diego State University)
 Blair Paley (U. California at Los Angeles)
 Edward Riley (San Diego State University)
 Sally Anderson (NIAAA, NIH)
 Kenneth R. Warren (NIAAA,NIH)
Special thanks to Bridget Grant
WHY WAS A DSM-5 DIAGNOSIS
NEEDED FOR INDIVIDUALS WITH AN
FASD?




There was no specific mental health code that adequately documents
the cognitive and mental health impact of PAE

Intellectual Deficiency

Cognitive impairment, NOS

Unspecified emotional and behavioral disturbance

ADD-ADHD
The existing diagnostic codes (760.71) do not adequately capture their
mental health needs)
Children with FASD may not respond to treatment regimens developed
using the existing codes similarly, which may lead to inappropriate
treatments
When seeking mental health care (assessments or interventions),
providers and families often struggle with obtaining appropriate
reimbursement for habilitative care
DSM-5 RELEASED MAY 2013
Need to advance the science
so it is accepted completely
as a disorder and receives its
own unique code
315.81
Pages 798-801
Classical Criteria for Psychiatric Diagnosis
(Blashfield & Draguns, 1976)
 Predictive validity-refers to the category being able to effectively
predict the individual’s responsiveness to different treatments.
 Coverage-the criteria being able to capture all individuals with the
condition
 Descriptive validity-refers to the homogeneity within the symptom
categories but not necessarily across the symptom
categories/domains
 Reliability-see the same child/information and the diagnosis is made
consistently by different clinicians
 Team reports and independently reviewing by clinicians to get an estimate of
reliability in making the diagnosis
 Compare experienced vs non-experienced (related to FASD) mental health
professionals in making the diagnosis
NEUROBEHAVIORAL DISORDER
ASSOCIATED WITH PRENATAL
ALCOHOL EXPOSURE
Symptoms
History of More
than Minimal
Levels of PAE*
ND-PAE
* >13 drinks per month or
more than 2 on one occasion
Domain:
Neurocognitive
Impairment
Domain:
Impairment
in Selfregulation
Domain:
Deficits in
Adaptive
Functioning Skills
•Global IQ (IQ < 70)
• Executive function impairment
• Learning impairment
• Memory impairment
• Visual spatial reasoning impairment
•Impairment in mood or behavioral
regulation
•Attention deficits
•Impairment in impulse control
•Communication deficit
•Social impairment
•Daily living skills impairment
•Motor impairment
LATENT TRAIT OF DISEASE SEVERITY
No
Symptoms
ND-PAE Disease Severity
Extreme
Symptoms
 Individuals with a history of PAE are anticipated to
have variability in ND-PAE symptomatology allowing
for a comparison of cohesiveness and necessity of
each item to identify the latent trait of disorder
severity.
SYMPTOM MAPPING
 This involves delineating how to positively endorse symptoms (code yes
or no)
 In a clinical context, symptoms are either present or absent based on
history or data available from standardized testing
 Existing databases can be used to assess the validity of the diagnosis with
test results and data serving as symptom indicators
 Deciding what the threshold is for clinical significance?
 2.0 STD Units-probably too restrictive
AF 2 of 4
AF 1
 1.5 STD Units
1.0 Cut-off
Model 1
Model 3
 1.0 STD Units
1.5 Cut-off
Model 2
Model 4
 Is the more restrictive criteria for adaptive functioning deficits needed?
 AF 2 of 4- Need two symptoms with one from social or
communication adaptive deficits
 AF-1- Only need one symptom with no restrictions on which one
• DAS IQ
• KBIT
COMPOS
ITE
• CBCL
Attention
• Medical
Dx or
ADHD
medicatio
ns
Domain
Neurocognitive
Symptom
Neurocognitive
Global Intellectual Functioning
Global Intellectual Functioning
Executive Functioning
Impairment In Learning
Impairment In Learning
Impairment In Learning
Impairment In Learning
Impairment In Learning
Impairment In Learning
Impairment In Memory
Impairment In Memory
Impairment In Memory
Impairment In Memory
Impairment In Memory
Neurocognitive
Impairment In Visual-Spatial Reasoning
Neurocognitive
Impairment In Visual-Spatial Reasoning
Neurocognitive
Impairment In Visual-Spatial Reasoning
Neurocognitive
Impairment In Visual-Spatial Reasoning
Neurocognitive
Impairment In Visual-Spatial Reasoning
Neurocognitive
Impairment In Visual-Spatial Reasoning
Neurocognitive
Neurocognitive
Neurocognitive
Neurocognitive
Neurocognitive
Neurocognitive
Neurocognitive
Neurocognitive
Neurocognitive
Neurocognitive
Neurocognitive
Neurocognitive
Specific Measure
DAS: GCA
K_BIT Composite
BRIEF Metacognitive Index
TEMA SS
KEYMATH TOTAL SS
TERA SS
Receiving SPEC Ed
Has An IEP
Repeated a grade
WISC_3 Letter Span
WISC-3 Spatial Span Total
WISC-3 Spatial Span Forward
WISC-3 Spatial Span Backwards
WIII-Auditory Working Memory
K-BIT Matrices
Visual SS from VMI
DAS: Nonverbal
DAS: Spatial
WJIII-Spatial Relations
WJIII-Visual Matching
n
56
55
56
56
42
56
48
47
45
56
56
56
56
56
55
56
56
56
55
55
% Positive % Positive
Endorseme Endorseme
nt (1.5 SD) nt (1.0 SD)
21.4
18.2
51.8
25.0
19.0
35.7
68.8
72.3
31.1
16.1
19.6
21.4
19.6
5.5
18.2
41.1
28.6
19.6
10.9
29.1
21.4
18.2
60.7
53.6
47.6
48.2
68.8
72.3
31.1
32.1
33.9
33.9
30.4
23.6
41.8
57.1
55.4
32.1
25.5
34.5
Specific Symptom Endorsement
Domain
Neurocognitive
Neurocognitive
Neurocognitive
Neurocognitive
Neurocognitive
Self-Regulation
Self-Regulation
Self-Regulation
Adaptive
Functioning
Adaptive
Functioning
Adaptive
Functioning
Adaptive
Functioning
Specific Symptom
% Positive
Endorsement
(1.5 SD)
% Positive
Endorsement
(1.0 SD)
Global Intellectual Functioning
Executive Functioning
Impairment In Learning
Impairment In Memory
Impairment In Visual-Spatial Reasoning
Impairment In Mood and Behavioral
Regulation
Attention Deficit
Impairment In Impulse Control
Adaptive Communication Deficit
26.8
51.8
80.4
33.9
64.3
85.7
26.8
60.7
87.5
51.8
83.9
89.3
82.1
69.6
55.4
92.9
76.8
71.4
Adaptive Social Impairment
64.3
82.1
Adaptive Impairment In Daily Living
48.2
73.2
Adaptive Motor Impairment
33.9
53.6
Breadth of
coverage is
good but not
when 1. 5 cut-of
used with 2 of 4
AF symptoms
Overall Domain and Diagnostic Endorsement
Neurocognitive
Self-Regulation
Adaptive
Functioning
Adaptive
Functioning
ND-PAE Diagnosis
ND-PAE Diagnosis
% Positive
Endorsement
(1.5 SD)
% Positive
Endorsement
(1.0 SD)
1 symptom
1 symptom
1 symptom
92.9
94.6
83.9
96.4
96.4
94.6
2 of 4 symptom
60.7
85.7
3 Symptoms (1 AF)
3 Symptoms (2 of 4 AF)
82.1
60.7
89.3
83.9
IntERNAL Consistency of 12 SymptomsCronBACH’s ALphA
Table 6. Equality of Group Means between Those Diagnosed or Not
Symptom
NI_1
NI_2
NI_3
NI_4
NI_5
SR_1
SR_2
SR_3
AF_1
AF_2
AF_3
AF_4
Threshold 1.5
Symptoms (AF1) TestStatistic
F (1,54)=4.67, p < .035
Threshold 1.5
Symptoms (AF2 of 4)
Test-Statistic
F (1,54)=10.5, p < .002
Threshold 1.0
Symptoms (AF1) TestStatistic
F (1,54)=2.5, p < .12
Threshold 1.0
Symptoms (AF2 of 4)
Test-Statistic
F (1,54)=4.1, p < .049
F (1,54)=9.68, p < .003
F (1,54)=6.2, p < .016
F (1,54)=2.1, p < .15
F (1,54)=7.3, p < .009
F (1,54)=7.85, p < .007
F (1,54)=1.3, p < .256
F (1,54)=2.7, p < .11
F (1,54)=0.9, p < .345
F (1,54)=6.79, p < .012
F (1,54)=11.7, p < .001
F (1,54)=0.9, p < .347
F (1,54)=3.9, p < .054
F (1,54)=6.76, p < .012
F (1,54)=9.8, p < .003
F (1,54)=15.9, p < .000
F (1,54)=15.3, p < .000
F (1,54)=2.48, p < .121
F (1,54)=10.5, p < .002
F (1,54)=13.0, p < .001
F (1,54)=15.9, p < .000
F (1,54)=9.76, p < .003
F (1,54)=5.1, p < .028
F (1,54)=7.7, p < .008
F (1,54)=3.8, p < .057
F (1,54)=0.52, p < .473 F (1,54)=0.35, p <
.852
F (1,54)=11.93, p < .001 F (1,54)=68.9, p < .000
F (1,54)=2.7, p < .104
F (1,54)=23.1, p < .000
F (1,54)=2.7, p <
.103
F (1,54)=8.5, p < .005
F (1,54)=20.90, p < .000
F (1,54)=34.0, p < .000
F (1,54)=13.1, p < .001
F (1,54)=47.6, p < .000
F (1,54)=7.87, p < .007
F (1,54)=35.5, p < .000
F (1,54)=13.1, p < .001
F (1,54)=32.6, p < .000
F (1,54)=3.18, p < .080
F (1,54)=4.2, p < .046
F (1,54)=3.8, p < .057
F (1,54)=8.7, p < .005
Receiver Operative Curve Area Under the Curve Analysis
by Cut-off Values Used on Standardized Measures
RELATIONSHIP OF SUM OF
SYMPTOMS TO PARTICIPANT
CHARACTERISTICS
 The sum of symptoms was not different between males and females
using both cut-off values but did differ by race with more symptoms
reported for African American children when using the 1.0 SD cut-off
value.
 The number of symptoms was not related to the child’s level of
dysmorphia, number of custody placements, child protective services
involvement, years of education, and household income.
 The number of symptoms was positively related to the child’s age for
both cut-off values (1.5 SD: r=.37, p < .006; 1.0 SD: r=.42, p < .001).
NEXT STEPS
 Assess these characteristics in a sample with a greater
dispersion of ND-PAE –an exposure sample with PAE
(CoFASP sample)
 Assess the symptoms and diagnostic formulations relative
to its ability to differentiate from typical controls and other
neurodevelopmental and behavior disorders (CIFASD
sample)