Developmental Behavioral Pedi 2014 Part 1

Today Honeybunches had the appointment with the Developmental Behavioral Pediatrician down at the big hospital we've been on the waiting list for since October. This was the intake appointment.  Then they'll do two more appointments: One for the ADOS and another to go over results/reports.

Today's was very beneficial. She told me that many parents have been having a hard time with the school districts regarding the new DSM-5 and whether or not children still have Autism (Although they are technically just supposed to be given the new Autism Spectrum Disorder diagnosis).

She observed him, asked him some questions, me some questions, had him fill out a questionnaire and went over some paperwork previously sent in.  She said even from our appointment today, just going over certain questions and mostly through observing/talking with him she can tell he meets ALL the new criteria for Autism Spectrum Disorder. 

"Diagnostic Criteria for 299.00 Autism Spectrum Disorder

1. 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. She said he met this one clearly.
   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 body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. She said he met this one too.
   3. Deficits in developing, maintaining, and understand 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. She said although he's developing some new friendships, he still meets this category too.

Specify current severity:
Severity is based on social communication impairments and restricted, repetitive patterns of behavior.

2. 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):She said he clearly meets all four, although to be diagnosed he only needed to meet two...
   1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, 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 of the 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).

Specify current severity:
Severity is based on social communication impairments and restricted, repetitive patterns of behavior. She did not go over his severity in detail as of yet...

3. 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).
4. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
5. 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 beloiw that expected for general developmental level.

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder."

She said although she could have confidently diagnosed him today, some school districts have been giving parents issues if they don't have a ADOS report to go along with the new DSM-5 diagnosis.  She said there is a new ADOS to go along with the new DSM. She said that doing the ADOS (Although not necessary) will help prevent any school questions in the future. So we go back in exactly four weeks for the ADOS appointment, then we'll have a follow up appointment just to go over the results. She clearly seen him persevering about wanting to eat lunch lol.  I told her how he smells everything.  She said while many children with different diagnoses have sensory issues in different ways, it's the smelling everything is Autism related.  I found that interesting. She also found it interesting how his intense interest area is money.  I mentioned to her how he can go to the store and bank 5+ times per day to change his money.  For example he can have a $10, go change it for two $5s. Come back and go change it for 5 $2s.  Then ten $1s... Etc. He knows the serial numbers, secretary and treasurers.  I told her his other favorite area of intense interest is trains.  She began asking him a couple questions about his favorite train.  He said Netfork Southern lol. 

She mentioned that she can see an underlying anxiety disorder.  I mentioned how he was previously diagnosed by a Developmental Behavioral Pedi at Tufts with Generalized Anxiety Disorder, but a more recent eval by a child psychiatrist at the hospital she is affiliated with said it was part of his Autism and Bipolar.  She said that while what was previously diagnosed as ADHD was part of it (She did not see the hyperness that goes along with that diagnosis), the anxiety disorder she believes is separate.  She said she'd want to be careful about labeling him as ADHD because then doctor's would be likely to try stimulants, which are often a disaster for "Children like him".  I then mentioned how his first med was Ritalin at age three which was a disaster. She gave me a questionnaire regarding anxiety to fill out for our next appointment.  She suggests getting him a Cognitive Eval (Which they also do in her office) when he is between 15-16 to help get adult services into place.  She said that at that age I will be "Concerned about his cognition and memory". ;) That's the age when differences with IQ become more prominent.

Another thing the doc mentioned was that she does not understand why they gave him the diagnosis of PDD-NOS instead of Classic Autism to begin with.  From observing him, she said it's very appearant. He previously scored "Severely Autistic" on the CARS rating scale back in 2009. I mentioned to her that the doc who diagnosed him said that the only reason she did not give him that diagnosis was because he could speak (Although he has Receptive-Expressive Language delays) and he also made limited eye contact (Which he did not do with this doctor today). I can see her evaluation being very helpful with Honeybunches three year IEP eval coming up in September.