Kaufmann Plenary

DSM 5 What You Need to Know Neurodevelopmental Disorders
San Diego Psychiatric Society June 8-9, 2013

Walter E. Kaufmann, M.D.
Department of Neurology Boston Childrens Hospital, Harvard Medical School
DSM-5: Framework
DSM-5: Conceptual Framework for NDDs

Aggression
Gastro-intestinal Dysfunction Sleep Disturbance Motor problems EpilepsyEEG abnormalities
Social Impairment ADHD
Autism Speech/SpectrumRepetitive Behaviors & Communication Disorder Restricted

Deficits Interests Intellectual Disability
Social Anxiety
Immune Dysfunction
OCD
Language Disorders
DSM-5: Framework
Conceptual framework for NDDs (I)

Lifelong disorder with onset during developmental periods: symptoms are unique to various ages/developmental stages and intellectual/language abilities. History & current impairment are needed. Impairment in personal, social, academic, and occupational functioning (adaptive functioning could measure impairment). Symptoms/impairments across settings: home, school, work, community. Evident when demands exceed limited capacity or support.
DSM-5: Framework
Conceptual framework for NDDs (II)

Importance of specifiers: Age of onset. Course Associated medical, genetic, and environmental condition/factor(s) Intellectual abilities Language abilities Severity NDDs frequently co-occur. Mental and behavioral disorders frequently cooccur.
DSM-5: Not that Profound Changes - ASD DSM-IV DSM-5
DSM-5: Rationale for Changes - ID
Problems with MR DSM-IV criteria (I)

1. Name of Mental Retardation has negative connotations. 1. Intellectual disability is already used medically, educationally, legally (Public Law 111-256, Rosas Law).
2. Four different definitions/criteria: DSM, American Psychological Association, AAIDD, WHO/ICD. Need for harmonization.
3. Intellectual disability is a mental disorder and a NDD. 4. Rigid application of IQ criteria underdiagnoses individuals in the mild-borderline range (i.e., IQ>70, Adaptive functioning <70). Forensic and other legal implications.
Problems with MR DSM-IV criteria (II)

6. Severity defined by IQ levels sometimes does not reflect level of intellectual functioning. 7. Confusion about definition of adaptive behavior area and number of areas of deficit. Need for empirical data.
Problems with MR DSM-IV criteria (III)

8. Greater knowledge about the genetics and neurobiology makes it difficult to define developmental period. Medical vs. educational/legal considerations.
DSM-5: Major Changes for NDDs
Intellectual Disability
Name change
Mental Retardation to Intellectual Disability Intellectual Developmental Disorder (postulated for ICD-11 since disability is for ICF)
Greater reliance on adaptive functioning for diagnosis, integrated by clinical judgment. Severity is determined by adaptive functioning rather than IQ. Broad adaptive domains rather than skill areas: conceptual, social & practical. Onset during developmental period, no age specified.
Intellectual Disability DSM-5 Diagnostic Criteria

Intellectual disability (intellectual developmental disorder) is a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains. The following three criteria must be met: A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, and academic learning and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing. 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. C. Onset of intellectual and adaptive deficits during the developmental period.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved.

Coding note: The ICD-9-CM code for intellectual disability (intellectual developmental disorder) is 319, which is assigned regardless of the severity specifier. The ICD-10-CM code depends on the severity specifier (see below). Specify current severity (F70) Mild (F71) Moderate (F72) Severe (F73) Profound

ICD-9-CM (until October 2014) 317 = Mild 318 = Other specified intellectual disability 318.0 = Moderate 318.1 = Severe 318.2 = Profound 319 = Unspecified Intellectual Disability ICD-10-CM (after October 2014) (F70) Mild (F71) Moderate (F72) Severe (F73) Profound (F78) Other intellectual disabilities (F79) Unspecified intellectual disabilities
Global Developmental Delay DSM-5 Diagnostic Criteria

315.8 (F88) This category applies to presentations in which symptoms characteristic of intellectual disability (intellectual development disorder) that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for intellectual disability or for any of the specific disorders in the neurodevelopmental disorders diagnostic class. This diagnosis is reserved for individuals under the age of 5 years when the clinical severity level cannot be reliably assessed during early childhood. This category requires reassessment after a period of time.
Unspecified Intellectual Disability (Intellectual Development Disorder) DSM-5 Diagnostic Criteria

319 (F79)
This category applies to presentations in which symptoms characteristic of intellectual disability (intellectual development disorder) that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for intellectual disability or for any of the specific disorders in the neurodevelopmental disorders diagnostic class. This category is reserved for individuals over the age of 5 years when assessment of the degree of intellectual disability by means of locally available procedures is rendered difficult or impossible because of associated sensory or physical impairments, as in blind, prelingual deafness; locomotor disability; or presence of severe problem behaviors or co-occurring mental disorder. This category should only be used in exceptional circumstances and requires reassessment after a period of time.
DSM-5: Rationale for Changes - ASD
Current Concept of Autism

1. Behavioral disorder/syndrome
2. Multiple etiologies: genetic and environmental
3. Lifelong disorder a) Different appearance (e.g., peer interactions change throughout life) b) Importance of early diagnosis c) Need for sustained support
4. Selective or greater impairment in social interaction 5. Common use of Autism Spectrum Disorder, including
Autistic Disorder and PDD-NOS
Concerns about ASD in DSM-IV

Validity of the Pervasive Developmental Disorders category Consistency of some diagnoses (e.g., high-functioning autistic disorder vs. Asperger) Appropriateness of the use of certain diagnoses (e.g., PDD-NOS as mild neurodevelopmental disorder, Asperger as odd behaviors) Validity of some diagnoses (e.g., childhood disintegrative disorder)
Autism in the Field

DSM-IV is NOT the Gold Standard Autism Diagnostic Interview-Revised (Rutter & Lord) is used by researchers and academic centers Clinicians use ICD autism criteria of social deficits plus RRBs CDC reports autism rates using all PDD categories
Autism Spectrum Disorder

Single category (No PDD category), single disorder (no PDD-NOS, Asperger, Autistic disorder, CDD) Name change: ASD Rett syndrome no longer a unique entity with category. Patients could meet criteria for ASD Two instead of three core domains: (1) deficits in
social communication and social interaction, (2) restricted repetitive behaviors, interests, and activities (RRBs). New entity: social communication disorder
Importance of specifiers and documenting severity.
DSM-5: The New Criteria
PDD-NOS in DSM-IV (Actually, PDD-NVS for Not Very Specific)

This category should be used when there is severe and pervasive development of reciprocal social interaction associated with impairment in either verbal or nonverbal communication skills OR with the presence of stereotyped behavior, interests and activities, but the criteria are not met for a specific PDD For example, this category includes atypical autism presentations that do not meet the criteria for Autistic disorder because of late age at onset, atypical symptomatology, or SUBTHRESHOLD SYMPTOMATOLOGY.
Name of Category
Delete the term Pervasive Developmental Disorders Symptoms are not pervasive they are specific to social-communication domain plus restricted, repetitive behaviors/fixated interests Overuse of PDD-NOS leads to diagnostic confusion (and may have contributed to autism epidemic) Overlap of PDD-NOS and Asperger disorder Recommend new diagnostic category: Autism Spectrum Disorder
Deletion of Rett Syndrome as a specific ASD

Rett will be removed as a separate disorder JUSTIFICATION: ASD behaviors are not particularly salient in Rett Syndrome patients except for brief period during development. ASD are defined by specific sets of behaviors, not etiologies (at present) so inclusion of Rett Disorder is unusual. Patients with Rett Syndrome who have autistic symptoms can still be described as having ASD, and clinicians should use the specifier with known genetic or medical condition to indicate symptoms are related to Rett.
Deletion of Childhood Disintegrative Disorder

New knowledge that developmental regression in ASD is a continuous variable, with wide range in the timing and nature of the loss of skills, as well as the developmental milestones that are reached prior to regression Rarity of CDD diagnosis makes systematic evaluation difficult, but review of accumulated worlds literature shows that CDD has important differences from other ASDs, including the acuity and severity of regression, as well as co-occurring physical symptoms, such as loss of bowel and bladder control. (Need to look for neurological disorder)
Elimination of Asperger Disorder

New diagnosis in DSM-IV with little difference from autism Criteria used in DSM-IV do not match the original cases described by Asperger (his cases meet autism criteria) No clinical or research evidence for separation of Asperger disorder from autism (High functioning autism = Asperger dx) Diagnostic biases apparent, with rich, white males receiving Asperger diagnosis, while poorer, non-Caucasian populations receive PDD-NOS diagnosis (See site differences in CDC surveillance data)
Merging of ASDs into a Single Diagnosis

AUTISM, ASPERGER and PDD-NOS will be collapsed into a single dx: AUTISM SPECTRUM DISORDER JUSTIFICATION: Scientific evidence and clinical practice show that a single spectrum better reflects the symptom presentation, timecourse and response to treatment Separation of ASD from typical development is reliable & valid while separation of disorders within the spectrum is not (e.g., Asperger and PDD-NOS used interchangeably, as are HFA and Asperger) Many states provide services only for dx of autism; as expected, PDD-NOS and Asperger disorder are rare dxs in those jurisdictions
Single Spectrum but Significant Individual Variability
Severity of ASD Symptoms Pattern of Onset and Clinical Course Etiologic factors Cognitive abilities (IQ) Associated conditions
CLINICIANS ARE ENCOURAGED TO DESCRIBE THESE DETAILS WITH DIAGNOSTIC SPECIFIERS
Proposed Changes: Number of Symptom Domains

THREE will become TWO Social Communication domain will be created by merger of key symptoms from the DSM-IV Social and Communication domains Fixated interests and repetitive behavior or activity JUSTIFICATION: Deficits in communication are intimately related to social deficits. The two are manifestations of a single set of symptoms that are often present in differing contexts. This de-emphasizes language skills not employed in the context of social communication. Fixes the double-counting problem of DSM-IV
Autism Spectrum Disorder DSM-5 Diagnostic Criteria

299.00 (F84.0)
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text): 1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. 2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and bodylanguage or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. 3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
Specify current severity. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved.

299.00 (F84.0)
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative not exhaustive; see text): 1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping plates, echolalia, idiosyncratic phrases). 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day). 3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). 4. Hyper-or hyporeactivity to sensory input or unusual interest in sensory aspects ofthe environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

299.00 (F84.0)
C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved .

Specify if: With or without accompanying intellectual impairment. With or without accompanying structural language impairment. Associated with a known medical or genetic condition or environmental factor. (Coding note: Use additional code to identify the associated medical or genetic condition). Associated with another neurodevelopmental, mental, or behavioral disorder. (Coding note: Use additional code[s] to identify the associated neurodevelopmental, mental, or behavioral disorder [s]).
With catatonia (refer to the criteria for catatonia associated with another mental disorder).(Coding note: Use additional code 293.89 [F06.1] catatonia associated with autism spectrum disorder to indicate the presence of the comorbid catatonia).
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved .

Severity is based on social communication impairments and restricted, repetitive patterns of behavior (Table 2).
DSM-5: Application of New Criteria
Concerns about ASD in DSM-5

Sensitivity has been sacrificed in order to improve specificity
Social communication domain Restrictive interests and repetitive behaviors domain
Merging Asperger disorder (and PDD-NOS) into autism spectrum disorder results in loss of identity and ignores uniqueness of Asperger dx Pre-/post DSM-5 research studies will not be comparable Changes in criteria threaten services delivery
Social Communication Disorder

Diagnosis is needed for: Children with current dx of PDD-NOS on the basis of social communication deficits Individuals with significant social skills deficits Criteria appeared to function well in field trials It is NOT included in ASD section because it defines a group of individuals with related, but separate symptoms
DSM-5: Major Changes for NDDs Social (Pragmatic) Communication Disorder DSM-5 Diagnostic Criteria
315.39 (F80.89)
A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by deficits in all of the following: 1. Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for the social context. 2. Impairment in the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on a playground, talking differently to a child than to an adult, and avoiding use of overly formal language. 3. Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction. 4. Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meanings of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation).
DSM-5: Major Changes for NDDs Social (Pragmatic) Communication Disorder DSM-5 Diagnostic Criteria
315.39 (F80.89)
B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination. C. The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities). D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder.
Attention-Deficit/Hyperactivity Disorder
Now among NDDs. No change in symptoms (18), symptom domains (inattention and hyperactivity/impulsivity), or number of required symptoms (6 in one domain). Application across life span (examples). Cross-situational requirement: several symptoms in each setting. Onset: several inattentive or hyperactive-impulsive symptoms were present prior to age 12 (before age 7). No subtypes, replaced with presentation specifiers. Comorbid diagnosis with ASD is now allowed. Symptom threshold for adults: five symptoms (both domains).

Attention-Deficit/Hyperactivity Disorder DSM-5 Diagnostic Criteria
A. Either (1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily side tracked). e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

A. Either (1) and/or (2):
2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. a. Often fidgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)
d. Often unable to play or engage in leisure activities quietly.

e. Is often on the go, acting as if driven by a motor (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings, etc.; may be experienced by others as being restless or difficult to keep up with). f. Often talks excessively. g. Often blurts out an answer before a question has been completed (e.g., completes peoples sentences; cannot wait for turn in conversation). h. Often has difficulty waiting his or her turn (e.g., while waiting in line). i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other peoples things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities). D. There is clear evidence that the symptoms interfere with, or reduce, the quality of social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

Specify whether: 314.01 (F90.2) Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivityimpulsivity) are met for the past 6 months. 314.00 (F90.0) Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months. 314.01 (F90.1) Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivityimpulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months. Specify if: In partial remission: When full criteria were met in the past, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning. Specify current severity: Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning. Moderate: Symptoms or functional impairment between mild and severe are present. Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.
DSM-5 Neurodevelopmental Disorders Workgroup

MEMBERS
Gillian Baird Ed Cook Francesca Happe James Harris* Walter Kaufmann* Bryan King* Catherine Lord Joseph Piven Rosemary Tannock Sally Rogers* Sarah Spence Susan Swedo (Fred Volkmar resigned in 09) Amy Wetherby Harry Wright *ID subgroup
ADVISORS
Jim Bodfish Martha Denckla Maureen Lefton-Grief Nickola Nelson Sally Ozonoff Diane Paul Eva Petkova Daniel Pine Alya Reeve Mabel Rice Joseph Sergeant Bennett & Sally Shaywitz Audrey Thurm Keith Widaman Warren Zigman

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DSM 5 What You Need to Know Neurodevelopmental Disorders

San Diego Psychiatric Society June 8-9, 2013

DSM-5: Conceptual Framework for NDDs

Social Impairment ADHD

Autism Speech/SpectrumRepetitive Behaviors & Communication Disorder Restricted

Conceptual framework for NDDs (I)

Conceptual framework for NDDs (II)

DSM-5: Not that Profound Changes - ASD DSM-IV DSM-5

DSM-5: Rationale for Changes - ID

Problems with MR DSM-IV criteria (I)

DSM-5: Rationale for Changes - ID

Problems with MR DSM-IV criteria (II)

DSM-5: Rationale for Changes - ID

Problems with MR DSM-IV criteria (III)

DSM-5: Major Changes for NDDs

DSM-5: Major Changes for NDDs

Intellectual Disability DSM-5 Diagnostic Criteria

DSM-5: Major Changes for NDDs

Intellectual Disability DSM-5 Diagnostic Criteria

DSM-5: Major Changes for NDDs

Intellectual Disability DSM-5 Diagnostic Criteria

DSM-5: Major Changes for NDDs

Global Developmental Delay DSM-5 Diagnostic Criteria

DSM-5: Major Changes for NDDs

Unspecified Intellectual Disability (Intellectual Development Disorder) DSM-5 Diagnostic Criteria

DSM-5: Rationale for Changes - ASD

Current Concept of Autism

Autistic Disorder and PDD-NOS

DSM-5: Rationale for Changes - ASD

Concerns about ASD in DSM-IV

DSM-5: Rationale for Changes - ASD

Autism in the Field

DSM-5: Major Changes for NDDs

Autism Spectrum Disorder

Importance of specifiers and documenting severity.

DSM-5: The New Criteria

PDD-NOS in DSM-IV (Actually, PDD-NVS for Not Very Specific)

DSM-5: The New Criteria

DSM-5: The New Criteria

Deletion of Rett Syndrome as a specific ASD

DSM-5: The New Criteria

Deletion of Childhood Disintegrative Disorder

DSM-5: The New Criteria

Elimination of Asperger Disorder

DSM-5: The New Criteria

Merging of ASDs into a Single Diagnosis

DSM-5: The New Criteria

Single Spectrum but Significant Individual Variability

CLINICIANS ARE ENCOURAGED TO DESCRIBE THESE DETAILS WITH DIAGNOSTIC SPECIFIERS

DSM-5: The New Criteria

Proposed Changes: Number of Symptom Domains

DSM-5: Major Changes for NDDs

Autism Spectrum Disorder DSM-5 Diagnostic Criteria

DSM-5: Major Changes for NDDs

Autism Spectrum Disorder DSM-5 Diagnostic Criteria

DSM-5: Major Changes for NDDs

Autism Spectrum Disorder DSM-5 Diagnostic Criteria

DSM-5: Major Changes for NDDs

Autism Spectrum Disorder DSM-5 Diagnostic Criteria

DSM-5: Major Changes for NDDs

Autism Spectrum Disorder DSM-5 Diagnostic Criteria

DSM-5: Major Changes for NDDs

Autism Spectrum Disorder DSM-5 Diagnostic Criteria