ARTICLE

DSM-V Changes for Autism

Spectrum Disorder (ASD):
Implications for Diagnosis,
Management, and Care
Coordination for Children
With ASDs
Sandra L. Lobar, PhD, APRN, PPCNP-BC

ABSTRACT practice nurse, and lack of understanding of ASD changes in

The purpose of this article is to highlight issues about the DSM-V may diminish the ability of advanced practice
diagnosis and management of autism spectrum disorders nurses to screen for ASDs and make the appropriate referrals.
(ASDs) in all settings, along with care coordination for all chil- J Pediatr Health Care. (2016) 30, 359-365.
dren with ASDs. The article outlines differences between the
American Psychiatric Association’s Diagnostic and Statistical
KEY WORDS
Manual of Mental Disorders, 4th edition, revised (DSM-IV-TR)
Asperger syndrome, autism spectrum disorder, Diagnostic
and the newer version (DSM-V) for ASDs. These changes may
and Statistical Manual of Mental Disorders, DSM, nurse prac-
limit the eligibility of some children for services in school,
titioner, Individualized Education Plan
leading to poorer social/academic outcomes, lower rates of
employment, and decreased assistance in eventual indepen-
dent living. Primary care providers identified a lack of knowl- The Centers for Disease Control and Prevention
edge regarding ASDs before the DSM-V was published, (CDC) continues to report alarming increases in the
describing difficulty in making ASD diagnoses, recognizing
numbers of children across the United States who
early symptoms of developmental concern, and managing
are diagnosed with autism spectrum disorder (ASD).
care. Care coordination is part of the role of the advanced
It was estimated that 1 in 68 children were diagnosed
with an ASD in 2010 (Baio, 2014), a 30% increase
Sandra L. Lobar, Associate Professor, College of Nursing and
Health Sciences, Florida International University, Miami, FL. from 2008, when the incidence was 1 in 88, and a 60%
increase from 2006, when the incidence was reported
Conflicts of interest: None to report.
to be 1 in 110 children. Some authors have suggested
Correspondence: Sandra L. Lobar, PhD, APRN, PPCNP-BC, that the ‘‘autism epidemic’’ has less to do with a true
Nicole Wertheim College of Nursing and Health Sciences, Florida
rise in prevalence than with greater awareness, clarifi-
International University, 11200 SW 8th Street ACH 3, Room 232,
Miami, FL 33199; e-mail: [email protected]. cation and/or expansion of the idea of what constitutes
an ASD, overidentification of the disorder, and/or
0891-5245/$36.00
use of the ASD label to establish service eligibility
Copyright Q 2016 by the National Association of Pediatric (McPartland, Reichow, & Volkmar, 2012).
Nurse Practitioners. Published by Elsevier Inc. All rights
As a result of the increased incidence and concerns
reserved.
about overdiagnosis, in May 2013, new guidelines for
Published online October 23, 2015. identification of ASDs were introduced in the fifth
http://dx.doi.org/10.1016/j.pedhc.2015.09.005 edition of the Diagnostic and Statistical Manual of

www.jpedhc.org July/August 2016 359

Mental Disorders (DSM-V) by the American Psychiatric the complications brought about by the numerous
Association (APA). However, rather than increasing comorbid conditions described for children considered
specificity for diagnosis and limiting overdiagnosis, to have ASDs, which occur at varying times and at
these guidelines may only serve to decrease eligibility different developmental levels for children (Levy,
for services for some children who may previously Mandell, & Schultz, 2009). This problem continues
have been considered to be on the autism spectrum even after the introduction of the DSM-V, because the
and are still in need of services (Volkmar & newer criteria mandate that symptoms be present
McPartland, 2014). from early childhood, even if the child does not have
Will, Barnfather, and Lesley (2013) stated that a clear symptoms until social demands exceed his or
primary care provider will encounter at least 11 children her ability to respond to situations. Unfortunately, it is
with ASD for every 1,000 children they see in their prac- often difficult to identify or describe social inadequacy
tice. A lack of understanding of the nuance of behaviors in early childhood, and although the criteria changes in
associated with an ASD and use of the new DSM-V the DSM-V encourage earlier diagnosis, these criteria
criteria may lead to the failure of advanced practice may lack the specificity for higher functioning children
nurses in primary care to fully identify children in (especially if they have comorbid disease) to be diag-
need of intervention. The 126 nurse practitioners who nosed even as they grow older.
were providers of primary care to pediatric patients The DSM includes core symptom domains and diag-
younger than 18 years in the study by Will et al. nostic features. A change from the DSM-IV-TR to the
(2013) described a significant lack of competency and DSM-V was a reduction in the core symptom domains.
barriers to providing care to children with ASDs. The The core symptom domains for ASD were reduced from
purpose of this article is to highlight issues related to the previous three to two: (1) impaired social communi-
the new DSM V criteria that relate to the diagnosis and cation and social interaction and (2) restricted, repeti-
management of ASDs in all settings and to discuss tive behaviors, interests, or activities (APA, 2013).
care coordination for all children with ASDs, but espe- Autistic disorder, Asperger syndrome, and pervasive
cially for children previously considered to be higher developmental delay were consolidated into a single
functioning or having Asperger disorder (syndrome). ASD classification as well. This change oversimplifies
the core symptom identification, making it more diffi-
A COMPARISON OF THE DSM-IV-TR AND DSM-V cult to determine just what behaviors may constitute
CRITERIA FOR DIAGNOSING ASDS an ASD and confusing providers. The description of
Prior to 2013, clinicians used the DSM-IV-TR as a primer the criteria does take the variability of functional impair-
for the diagnosis of ASDs. In that version of the manual, ment into consideration by warning of the effects of
several disorders were seen as part of a group of perva- context such as environment and developmental stage.
sive developmental disorders (PDDs) that later became Behaviors indicative of these core symptoms may
known as the autism spectrum of disorders. These dis- be present but may be difficult to discern in certain
orders included autistic disorder, Asperger disorder, contexts, or the individual characteristics may be less
and general PDD. A number of criteria for ASD and spe- obvious in certain environments or during certain
cific categories have been altered for the DSM-V criteria developmental stages. Thus manifestations of the disor-
(Volkmar & McPartland, 2014). der are exceptionally varied.
A major change from the DSM-IV-TR to the DSM-V The diagnostic features related to an ASD in the
was that the overarching umbrella term of PDD was DSM-V have four major criteria: (a) continuous impair-
changed for the DSM-V criteria. What was previously ment in interaction and communication that are recip-
characterized in the DSM-IV-TR as an ‘‘umbrella’’ of rocal and social in nature; (b) patterns of activities,
PDDs with subcategories (APA, 2000) is now a broader interests, and behaviors that are restricted and repeti-
concept of a ‘‘spectrum’’ of disorders. This change adds tive; (c) symptoms that are persistent from early child-
to the notion that ASDs are not discrete disorders under hood; and (d) symptoms that interfere with everyday
one umbrella term but are on a spectrum of similar functioning. These criteria also include a requirement
disorders with varying presentations and severity of that characteristics of the individual’s symptoms
behavior. Concern about limitations in identifying impede functioning, especially in social and occupa-
the subcategories reliably was of concern to many diag- tional areas. In addition, social communication deficits
nosticians, thus prompting this change (Volkmar & should not be related to the individual’s level of devel-
McPartland, 2014). With this change from categorical opment. There should be an assessment of whether
description of discrete disorders to the spectrum, diag- impairments to functioning exceed any problems
nosticians were expected to view ASD as a continuum expected based on developmental level (APA, 2013).
of mild to more severe symptoms (APA, 2013). Children with characteristics associated with an ASD
Many clinicians found that identifying persons with lack the ability to interact with others in positive ways,
autism or ASD was difficult given the many variations according to the DSM-V. At home, children with charac-
in symptoms and behaviors, especially considering teristics of an ASD may not do well with a lack of order

360 Volume 30  Number 4 Journal of Pediatric Health Care

or routine. These children often have problems with gest that higher functioning individuals would not meet
planning, organization, and coping, which cause diffi- the DSM-V criteria for an ASD.
culty in academic situations (APA, 2013).
Focus on the idea of functionality or the ability of the HIGH-FUNCTIONING CHILDREN WITH ASD
individual to function according to his or her own (FORMERLY KNOWN AS ASPERGER DISORDER)
perception is a part of the DSM-V (APA, 2013). Age Although the ASD definition in the DSM-V does include
and environmental context affect the child’s perception disorders previously referred to as autism, high-
of the situation and the presentation of characteristics of functioning autism, pervasive developmental delay,
ASDs. Learning for younger children who are not in pervasive developmental delay not otherwise speci-
school usually takes place through social interaction fied, and Asperger disorder, these diagnoses are much
with peers in the playground or with parents at home. less clear in the DSM-V (APA, 2013). In the current
If the environmental context is not conducive to social DSM-V criteria for ASD diagnosis, the diagnostic criteria
interaction and enhancement of social communication, tends toward what was once referred to as ‘‘classic
this may have an impact on behaviors and, in turn, the autistic disease,’’ in which children may have obvious
appropriate diagnosis. motor signs of an ASD, lower cognition, and/or poor
The authors of the DSM-V have created the new diag- to nonverbal responses. The DSM-V criteria, therefore,
nosis of social (pragmatic) communication disorder. may raise the ‘‘diagnosis threshold’’ or proverbial diag-
This addition may confuse diagnosticians and prevent nostic ‘‘bar’’ for higher functioning, less cognitively
accurate diagnosis of children with a potential ASD. impaired children, especially children with the constel-
The diagnostic domains in social communication disor- lation of behaviors and symptoms formerly classified as
der may overlap with ASD under the determination Asperger syndrome (McPartland et al., 2012). Concerns
of impaired verbal communication. It is unclear how have been raised that as a result of these new guidelines
severity is determined in these criteria because there many children who once were diagnosed with an ASD
is no way to show the effects of even what is considered may no longer be considered to have an ASD or that
mild problems with social communication. Children they may fail to be diagnosed at all (Gibbs et al., 2012).
with impaired social communication could receive a Asperger disorder was characterized in the DSM-
diagnosis of social (pragmatic) communication disor- IV-TR as impairment in social interaction (severe and
der instead of a diagnosis of ASD (APA, 2013; Young sustained) causing problems in areas of functioning in
& Rodi, 2013). social and occupational domains. Differences in autism
disorder and Asperger disorder in the DSM-IV-TR
DIAGNOSTIC SENSITIVITY OF THE DSM-V FOR reflected the emphasis on the social aspects of commu-
ASD nication such as reciprocal social interaction (APA,
The DSM-V criteria have been tested in a number 2000) rather than an emphasis on the severity of
of clinical settings with mixed results. Huerta et al. other diagnostic symptoms such as repetitive behaviors
(2012) assessed previously collected data for symptoms and/or restrictive interests.
of PPD under the newer DSM-V criteria for ASDs. They Social communication has been described as a major
found that 91% of children with a previous diagnosis of area of concern for children with Asperger disorder,
PDD would retain their diagnosis under the newer defined as a ‘‘higher functioning’’ type of ASD. Asperger
DSM-V. However, other diagnosticians have found disorder includes persons with early or age-appropriate
that the DSM-V has not been sensitive for symptoms development of speech; however, the reciprocal social
of Asperger disorder, and other exploratory studies interaction in body movement and use of speech is
have demonstrated lower sensitivities for a diagnosis where persons with Asperger disorder have the most
of ASD using the DSM-V criteria to identify children difficulty and fit for the previous DSM-IV-TR criteria
(Gibbs, Aldridge, Chandler, Witzlsperger, & Smith, for a diagnosis of an ASD (Lobar, Fritts, Arbide, &
2012; McPartland et al., 2012). Russel, 2008). Pertinent characteristics of Asperger
It is not the wording or the inclusion/exclusion syndrome include perceptual, emotional, conceptual,
criteria that are of concern in making these diagnoses. and memorization issues (Jordan, 2005). Asperger
What is of concern is that the diagnosis of an ASD is syndrome was initially described to include verbal pre-
only made when all three criteria are met in the cocity and motor clumsiness and was indicated by a
social-communication domain and at least two criteria positive family history (McPartland et al., 2012).
are met from the behaviors domain (McPartland et al., Many versions of the defining characteristics of
2012; Young & Rodi, 2013). In a study of diagnosis Asperger syndrome have existed since the original
and changes in the DSM criteria, Young and Rodi definition of the syndrome was proposed by Asperger
found that 57% of 210 children already diagnosed in 1944. Now it is included in the DSM-V, on the
with an ASD under the DSM-IV-TR would not qualify spectrum of ASD, but with limited description (APA,
for diagnosis under the DSM-V. Thus these authors sug- 2013; Volkmar & McPartland, 2014). The diagnosis of

www.jpedhc.org July/August 2016 361

Asperger syndrome previously caused problems in the psychologists, psychiatrists, neurologists, and other
completion of research studies that were performed to health care practitioners) used a variety of measures
clarify diagnosis and determine the efficacy of and observations to ascertain which of the supposedly
interventions. Persons with Asperger syndrome and ‘‘discrete’’ disorders under the ASD umbrella that a
pervasive developmental delay (also considered child’s complex symptoms might indicate. Parents
‘‘higher functioning’’) have many of the same must be involved in evaluation and coordination of ser-
problems that grossly affect all areas of daily living, vices based on these diagnoses (Florida Department of
especially in the school setting (Teitelbaum et al., 2004). Education, Division of Public Schools, Bureau of
Exceptional Education and Student Services (BEESS),
BARRIERS TO DIAGNOSIS AND MANAGEMENT 2012; Feinberg & Ladew, 2011).
AFTER IMPLEMENTATION OF THE DSM-V
Lobar, Fritts, Arbide, and Russell (2008) discussed diffi- DIAGNOSTIC ASSESSMENTS BEYOND THE DSM
culties in diagnosing Asperger disorder and the conse- Volkmar and McPartland (2014) noted that assessment
quences of being marginalized in the academic setting includes much more than just the DSM criteria.
because the indicators are not recognized by many pri- Screening assessments and instruments have been
mary care providers. These authors highlighted the used in addition to the DSM criteria with varied effects
descriptors and indicators that characterize children because of the nature of the instruments. Some of these
with Asperger syndrome. Behaviorally, children with instruments and assessments rate the deviation from the
Asperger disorder (or syndrome) tend to be clumsy norm, whereas others rate the severity of symptoms
or dyspraxic, hyperactive, impulsive, and lacking in within the diagnostic category. All of these issues may
judgment. Symptomatically, they may have pedantic complicate the purpose of the diagnosis and the inter-
or oddly toned speech that begins in the preschool ventions used to help children and their families with
years. They demonstrate difficulty with sharing in services.
preschool, reciprocal speech, maintenance of peer Most symptom checklists are completed by parents.
relationships, poor use of personal/social space, and Many parents will not be able to identify reciprocal
unusual sensations and attentional states, all of which and social symptoms accurately at younger ages
affect their behavior and success in all settings (school when developmental levels may be the cause for
and social). Often shunned or bullied, their self- many such behaviors. For example, 2- to 3-year-olds
esteem is damaged, and they underachieve in school. displaying anger, temper tantrums, and obstinate
Excessive exposure to hypersensitivities such as sound behaviors may not be seen by parents as having prob-
that may be innocuous to the neurotypical child can lems in interaction. Children who point to objects rather
trigger overarousal, severe agitation, and panic (APA, than ask for them at ages 3 to 5 years may just be replay-
2000; Lobar et al., 2008). ing a parent’s question as to what they desire instead of
exhibiting lack of speech.
DIAGNOSIS AND MANAGEMENT OF ASD IN THE Diagnostic and screening tools such as the Modified
MEDICAL HOME BY PRIMARY CARE Checklist for Autism in Toddlers may still be used to
PROVIDERS determine the possibility of the disorders; however, it
Liptak, Stuart, and Auringer (2006) studied a national is recommended that multiple instruments specific
sample of 80 children diagnosed with ASD across the to the symptoms and context of the behaviors be
United States. Surveys from the Medical Expenditure used. Interviews with caregivers, questionnaires about
Panel and National (Hospital) Ambulatory Medical behaviors, and observations by primary care providers
Care were used to compare children diagnosed with in different contexts will increase the reliability of diag-
ASD (according to the DSM-IV-TR) with the general noses over time (APA, 2013). Problems with intellectual
population in pediatric settings. Children with ASD abilities may obscure the diagnosis because there are
were found to have more medications prescribed and other diagnoses more appropriate to this category,
more outpatient visits, and they spent more time with such as intellectual disability.
the physician provider than did other children. The
data suggested that children with an ASD incur a signif- CARE COORDINATION AND EDUCATIONAL
icant financial burden as well, with annual expenses MANAGEMENT AND SERVICES FOR
for children with ASD reported at an average of HIGH-FUNCTIONING CHILDREN WITH ASD
$6,132 compared with ‘‘other children’’ with an average Hyman and Johnson (2012) noted that children with
expenditure of $860. ASDs and their families would receive more continuity
As part of the umbrella of disorders classified under of care, increased screening, and developmental
the previous criteria, the DSM-IV-TR, children with surveillance, as well as better management of care
Asperger disorder and pervasive developmental delay (including needed services), in the medical home (a
qualified for services under the Individuals with Dis- primary pediatric setting). The medical home concept
abilities Education Act. Diagnosticians (ranging from was developed by the Maternal Child Health Bureau

362 Volume 30  Number 4 Journal of Pediatric Health Care

in collaboration with the American Academy of Pediat- intervention and facilitation of IEP goals. No studies
rics (AAP) to promote family centered, continuous were found in a review of literature related to primary
and comprehensive, compassionate and culturally care providers, diagnosis of ASDs, care coordination,
effected care (National Center for Medical Home and school communication; however, a majority of
Implementation, American Academy of Pediatrics, the services needed by school-aged children are coor-
n.d.). Additionally, the medical home has been identi- dinated by the school if the child is in a public educa-
fied as a possible partnership between families and pro- tional institution (Center for Parent Information and
viders that supports access to and use of needed Resources, 2007; Feinberg & Ladew, 2011; Florida
services and community support necessitated by Department of Education, Division of Public
the child’s care needs (Sadof & Nazarian, 2007). Unfor- Schools, BEESS, 2012).
tunately, this is not currently the case. Diagnosis and The AAP has defined care coordination as
management of ASDs in the medical home would happening when a plan of care is implemented by a
require an understanding of the changes in diagnostic variety of service providers in an organized way
criteria, in-depth knowledge of developmental differ- (AAP, 2005). The providers responsible for care coor-
ences found in children with ASDs, and the ability of dination have a role in education, communication,
the provider to help the family coordinate care with and resource provision for children and families
specialty services (Johnson, Myers, & The Council on (AAP, 2005). Benefits of care coordination should
Children with Disabilities, 2007). include reduced school absenteeism, limited visits to
Providers in primary medical home care include emergency departments, access to resources, and
pediatricians, nurse practitioners, and/or physician increasing skills in self-management and transitions
assistants with varied training, and it is not known for families and their children (McAllister, Presler, &
how this may affect the actual diagnosis of ASDs and Cooley, 2007).
level of severity (Hyman & Johnson, 2012). The health Care coordination must include communication with
care provider in the medical home comes into contact the school. Some students, especially those with an
with parents more often than other providers of ASD, may not be part of the general education but
specialty care and should be the first to hear parental may require special education programs because of
concerns. Lobar (2014) found that parents of children learning disabilities or exceptional abilities. Children
diagnosed with an ASD had many concerns about with symptoms of ASD (including those who are
service access and the appropriateness of services, considered ‘‘higher functioning’’) usually require assis-
especially in the school setting. tive educational services and an IEP. The IEP is a
Carbone, Behl, Azor, and Murphy (2009) used focus tangible plan that outlines the special education and
groups to compare parents’ and physicians’ percep- services needed by these children individually and,
tions of the medical home for children suspected of by law, is provided free of charge (Feinberg & Ladew,
having an ASD and those already diagnosed. They 2011).
found that participants, both parents and pediatricians, An IEP must be developed after determination of
described the medical home as ‘‘lacking’’ in meeting the eligibility based on procedures such as aptitude and
needs of children with ASDs. Parents stated that they achievement tests, parent input, and teacher recom-
did not feel that pediatricians responded to their con- mendation that confirm a learning disability. Specific
cerns about child development in a timely fashion learning disabilities include inadequate performance
and that care did not meet the goals of the medical in oral expression, listening comprehension, written
home (i.e., care that is family-centered, comprehensive, expression, basic reading or reading fluency skills,
and coordinated). Pediatricians talked about a lack of reading comprehension, mathematics calculation, and
time, training, and resources to implement the goals problem solving (Center for Parent Information and
of the medical home. Resources, 2007). Learning disabilities often stem
Specialty services are often provided in the school from diagnoses such as ASDs or other developmental
while children are in regular or special education clas- disabilities.
ses when they have a diagnostic label as having an The IEP is developed, reviewed, and revised in
ASD. Bellando and Lopez (2009) suggested that school a meeting with the IEP team composed of the parent,
nurses are very important to the process of school regular teacher, special education teacher, a school
intervention for children with ASDs in that they might representative, and/or other professionals such as a
assist in early identification and interventions for psychologist, speech therapist, or occupational
health issues. These authors also suggested that the therapist, according to the child’s needs. The state-
school nurse is responsible for the individual health ment must include present levels of achievement,
record, noting any health concerns and interventions how the disabilities affect learning, specific measur-
for children in school and the Individualized Educa- able goals, progress toward goals, periodic
tional Plan (IEP). These authors also noted that the reports, participation with nondisabled children,
school nurse should be a member of a team effort for and accommodations for assessments (Center for

www.jpedhc.org July/August 2016 363

Parent Information and Resources, 2007). Besides disorders. They found that lower cognitive ability
being a legal requirement, the IEP should be an and communication skills were associated with the
effective tool when developed and used correctly types of placement in special education and main-
to meet the special needs of children with disabil- streaming and that most of the children in this study
ities. However, as with any other intervention, effi- stayed the same placement in which they began in
cacy depends on inherent inaccuracies that may be school in the first grade. Students did receive special
caused by inadequate assessment, unrealistic goals, services in school with emphasis placed on their cogni-
and other causes such as limited use or misuse of tive ability rather than any social problem that may
the IEP. Periodic reports and revision of the IEP interfere with schooling, academic success, and transi-
should help assess and address any weaknesses. tions to middle school, high school, and beyond.

THE NURSE PRACTITIONER, SCHOOL, AND CONCLUSION

CHILDREN WITH ASDS Changes in the DSM-V have altered the landscape of
diagnosis and intervention for children who may have
Falkmer, Anderson, Falkmer, and Horlin (2013) noted
qualified as having an ASD under the previous DSM-
that diagnosing an ASD is time consuming, requiring a
IV-TR criteria. Children previously diagnosed with
multidisciplinary approach to assessing all informa-
Asperger syndrome or pervasive developmental delay
tion such as development and behavioral history.
may not meet criteria for services in school under
The primary care setting in the medical home is ill
the DSM-V, impacting both children and their parents
equipped for such an approach. One way to alleviate
this problem is to use the school setting as an initial in managing their symptoms. Additionally, the push
point of evaluation, referral, and/or care coordination. to diagnose these
children in a medical Children previously
School psychologists can be helpful in this setting as
home setting has met
part of the team of professionals to evaluate the child diagnosed with
with certain problems
not only for whether they have an ASD but what the
child’s educational needs may be. School nurse practi-
related to continuity of Asperger
services and care coor- syndrome or
tioners have been identified as key personnel in the
dination. The school
school setting to facilitate care coordination in diag- pervasive
nosis, referral, and management of needs. Setting pri- system has a major
orities for an individual health plan and/or role in determining developmental
the types of interven- delay may not meet
participating in the development of goals for the IEP
tions that are imple-
would help the school nurse practitioner intervene criteria for services
mented for children
with students and families to promote better care coor-
dination because they are involved in the school and
with a potential diag- in school under the
nosis of ASD. Health DSM-V, impacting
have knowledge of the child’s needs (Bellando &
care professionals in
Lopez, 2009). both children and
Mossman Steiner, Goldsmith, Snow, and Chawarska communication with
(2012) noted the difficulties of completing a structured the school system may their parents in
be in the best position managing their
assessment with children who have ASDs. They stated
to assess children and
that the most significant factor in influencing the out- symptoms.
to offer their services
comes of an ASD screening is where the diagnostic pro-
in care coordination,
cess takes place. According to this group, if a child is
thus leading to better academic outcomes, employment
assessed in an environment that accommodates his or
opportunities, and eventually greater independent
her attentional and learning style and motivational fac-
tors, even a child with the most challenging behavioral living.
traits can complete a standard assessment. The DSM-5
Many thanks to the master’s students who helped
explicitly states ‘‘symptoms may not be fully manifest
with a review of the literature.
until social demand exceeds capacity’’ for the child
with an ASD (APA, 2013; Coury et al., 2014, p. 29).
The goal of both the DSM-5 and the academic team is REFERENCES
to determine the severity of the child’s needs in order American Academy of Pediatrics. (2005). Care coordination in the
to identify the interventions most likely to optimize so- medical home: Integrating health and related systems of care
cial competence and minimize hypersensitivities. for children with special health care needs. Pediatrics, 116(5),
White, Scahill, Klin, Koenig, & Volkmar (2007) stud- 1238-1244.
American Psychiatric Association. (2000). Pervasive developmental
ied child characteristics associated with educational disorders. In: Diagnostic and statistical manual of mental disor-
placement and service use for children identified ders (4th ed. rev., pp. 69-84). Arlington, VA: American Psychi-
as high-functioning and on the autistic spectrum of atric Association.

364 Volume 30  Number 4 Journal of Pediatric Health Care

American Psychiatric Association. (2013). Neurodevelopmental dis- Jordan, R. (2005). Managing autism and Asperger’s syndrome in
orders. Autism spectrum disorder. In: Diagnostic and statistical current educational provision. Pediatric Rehabilitation, 8(2),
manual of mental disorders (5th ed.). Arlington, VA: American 104-112.
Psychiatric Association. Levy, S. E., Mandell, D., & Schultz, R. T. (2009). Autism. Lancet,
Baio, C. (2014). Prevalence of autism spectrum disorders among 374(9701), 1627-1638.
children aged 8 years—Autism and Developmental Disabilities Liptak, G. S., Stuart, T., & Auringer, P. (2006). Health care utilization
Monitoring Network, 11 sites, United States, 2010. Morbidity and expenditures for children with autism: Data from U.S.
and Mortality Weekly Report, 63(SS02), 1-21, Retrieved from national samples. Journal of Autism and Developmental Disor-
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6302a1.htm ders, 36, 871-879.
?s_cid=ss6302a1_w Lobar, S. L. (2014). Family adjustment across cultural groups in
Bellando, J., & Lopez, M. (2009). The school nurse’s role in treatment autistic spectrum disorders. Advances in Nursing Science,
of the student with autism spectrum disorders. Journal for Spe- 37(2), 174-186.
cialists in Pediatric Nursing, 14(3), 173-181. Lobar, S. L., Fritts, M. K., Arbide, A., & Russell, D. (2008). The role of
Carbone, P. S., Behl, D. D., Azor, V., & Murphy, N. A. (2009). The the nurse practitioner in an individualized education plan and
medical home for children with autism spectrum disorders: coordination of care for the child with Asperger’s syndrome.
Parent and pediatrician perspectives. Journal of Autism and Journal of Pediatric Health Care, 22(2), 111-119.
Developmental Disorders, 40(3), 317-324. McAllister, J. W., Presler, E., & Cooley, W. C. (2007). Practice-based
Center for Parent Information and Resources. (2007). Subpart D of care coordination: A medical home essential. Pediatrics, 120(3),
the part B regulations: Evaluations, eligibility, IEPs, and place- 723-733.
ment. Retrieved from http://www.parentcenterhub.org/repo McPartland, J. C., Reichow, B., & Volkmar, F. R. (2012). Sensitivity
sitory/partb-subpartd/#300.306 and specificity of proposed DSM-5 diagnostic criteria for autism
Coury, D. L., Swedo, S. E., Thurm, A. E., Miller, D. T., Veenstra- spectrum disorder. Journal of the American Academy of Child &
VanderWeele, J. M., Carbonne, P. S., . Lounds Taylor, J. Adolescent Psychiatry, 51(4), 368-383.
(2014). Treating the whole person with autism: The proceedings Mossman Steiner, A., Goldsmith, T. R., Snow, A. V., & Chawarska, K.
of the Autism Speaks National Autism Conference. Current (2012). Practitioner’s guide to assessment of autism spectrum
Problems in Pediatric and Adolescent Health Care, 44(2), 26-47. disorders in infants and toddlers. Journal of Autism and Devel-
Falkmer, T., Andreson, K., Falkmer, M., & Horlin, C. (2013). Diag- opmental Disorders, 42(6), 1183-1196.
nostic procedures in autism spectrum disorders: A systematic National Center for Medical Home Implementation, American Acad-
literature review. European Child Psychiatry, 22(6), 329-340. emy of Pediatrics. (n.d.) What is a family-centered medical
Feinberg, A., & Ladew, P. (2011). Active duty: Helping parents home? Retrieved from http://www.medicalhomeinfo.org/about/
become effective members of their child’s IEP team. Excep- medical_home/index.aspx
tional Parent, 41(9), 36-39. Sadof, M. D., & Nazarian, B. L. (2007). Caring for children who have
Florida Department of Education, Division of Public Schools, Bureau special health-care needs: A practical guide for the primary care
of Exceptional Education and Student Services. (2012). A par- practitioner. Pediatric Review, 28(7), 36-42.
ent’s introduction to exceptional student education in Florida. Teitelbaum, O., Benton, T., Shah, P. K., Prince, A., Kelly, J. L., &
Retrieved from http://www.fldoe.org/core/fileparse.php/7690/ Teitelbaum, P. (2004). Eshkol-Wachman movement notation
urlt/0070085-eseparent.pdf in diagnosis: The early detection of Asperger’s syndrome. Pro-
Gibbs, V., Aldridge, F., Chandler, F., Witzlsperger, E., & Smith, K. ceedings of the National Academy of Sciences, 101(32),
(2012). Brief report: An exploratory study comparing diagnostic 11909-11914.
outcomes for autism spectrum disorder under DSM-IV-TR with Volkmar, F. R., & McPartland, J. (2014). From Kanner to DSM-5:
the proposed DSM-5 Revision. Journal of Autism & Develop- Autism as an evolving diagnostic concept. Annual Review of
mental Disorders, 42, 1750-1756. Clinical Psychology, 10, 193-212.
Huerta, M., Bishop, S. L., Duncan, A., Hus, V., & Lord, C. (2012). White, S. W., Scahill, L., Klin, A., Koenig, K., & Volkmar, F. R. (2007).
Application of the DSM-5 criteria for autism spectrum disorder Educational placements and service use patterns of individuals
to three samples of children with DSM-IV diagnoses of perva- with autism spectrum disorders. Journal of Autism and Devel-
sive developmental disorders. American Journal of Psychiatry, opmental Disorders, 37(8), 1403-1412.
169(10), 1056-1064. Will, D., Barnfather, J., & Lesley, M. (2013). Self-perceived autism
Hyman, S. L., & Johnson, J. K. (2012). Autism and the pediatric prac- competency of primary care nurse practitioners. The Journal
tice: Toward a medical home. Journal of Autism & Develop- for Nurse Practitioners, 9(6), 350-355.
mental Disorders, 42(6), 1156-1164. Young, R. L., & Rodi, M. L. (2013). Redefining autism spectrum dis-
Johnson, C. P., Myers, S. M. & Council on Children With Disabilities. order using DSM-5: The implications of the proposed DSM-5
(2007). Identification and evaluation of children with autism criteria for autism spectrum disorders. Journal of Autism Devel-
spectrum disorders. Pediatrics, 120(5), 1183-1215. opmental Disorders, 44, 758-763.

www.jpedhc.org July/August 2016 365