Autism and the DSM-5

There has been a lot of talk in the media about the forthcoming DSM-5 and the diagnosis of Autism.  The DSM-5 is the Fifth Edition of the Diagnostic and Statistical Manual used by Doctors to make diagnoses pertaining to Autism and other behavioral and mental health disorders.  There are in fact two major changes in this newest edition regarding Autism.  The first has to do with changes to the name of the diagnosis.  The second has to do with the actual diagnostic criteria used to make a diagnosis.


Currently, when presented with a child who exhibits some characteristics of Autism, Doctors have to determine whether or not the child exhibits a sufficient array of clinically significant symptoms to warrant a diagnosis.  This process requires the clinician to rule out other disorders that may instead be causing the problematic symptoms.  The clinician also has to make a differential diagnosis to determine which of the Pervasive Developmental Disorders best describes the child.  Many professionals, me included, believe that the dividing lines between the various forms of Autism are difficult to distinguish.  The new DSM does away with this problem by eliminating the different labels (Autistic Disorder, Asperger’s Disorder, PDD-NOS, Childhood Disintegrative Disorder) and instead puts in place a more general term – Autism Spectrum Disorder (ASD).  Many researchers and clinicians agree that this change is warranted.


When the DSM-5 is published in May of 2013, children who previously would have been diagnosed with Autistic Disorder, Asperger’s Disorder, or PDD-NOS, will be given the new diagnosis – Autistic Spectrum Disorder (ASD).  A differentiation will then be made by indicating the degree of symptom severity.  Specifically, those with more classical Autism will be diagnosed with ASD-Severe.  At the other end of the spectrum, children diagnosed with Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS) will likely get an ASD-Mild designation.  Those with Asperger’s may fall anywhere from ASD-Severe to ASD-Mild, depending on the degree of impairment.  Many with Asperger’s will likely fall in the Moderate range.  To be clear however, Classical Autism may span Severe to Mild ASD while PDD-NOS will likely span Moderate to Mild ASD.  Again, the severity designation depends on the number and severity of symptoms present.  If your child already carries a diagnosis, little will change, except perhaps how professionals refer to the disorder itself.   Your child will be referred to as being on the Autistic Spectrum.


The second change involves a modification of the Diagnostic Criterion used to provide a diagnosis.  When making a diagnosis, a clinician such as myself, has to have evidence of a sufficient array of behaviors listed in the DSM in order to provide a diagnosis.  The behaviors commonly associated with Autism make up the list of Diagnostic Criterion in the manual.  The new DSM includes an update of the behaviors used as these criteria.  It defines ASD by two sets of core features, namely: 1) impaired social communication and social interactions; and 2) restricted and repetitive behavior and interests. It more appropriately reorganizes the symptoms in these domains and adds sensory interests and sensory aversions to the list.


The new version is touted as an improvement because it adds to and reorganizes the diagnostic criterion so that they better address the needs of people with ASD across all developmental levels and ages.  It also includes improvements to better address the atypical symptom presentation of girls.  The goal of DSM-5 is to apply what is detailed in the scientific literature so as to add precision and validity to the diagnostic process.


As with any change, there have been some concerns expressed in the media.  Perhaps the most frequently heard concern is the fear that those at the mildest end of the spectrum with strong cognitive capabilities will no longer qualify for the diagnosis and thus may lose services.  Advocacy groups such as Autism Speaks have been actively engaging in this reorganization process and the American Psychiatric Association (the publisher of the DSM) has made statements aimed to calm the concerns.  They suggest that clinical judgment remains a crucial piece of the diagnostic process and that the new criteria are designed to be completely inclusive of those diagnosed using the current DSM-IV.  The research released by the American Psychiatric Association shows improved reliability and validity of diagnoses using the DSM-5 and strong inclusiveness of those already diagnosed using the DSM-IV.  I have seen the proposed diagnostic criterion and upon review I did not have any serious concerns with regard to how it will affect my ability to make diagnoses.


The bottom line is that for most parents, there will be no appreciable change other than how we refer to your child.  In anticipation of this change we have already been using the phrase Autism Spectrum Disorder or “on the spectrum” for quite some time now.  Diagnoses in the near term will still be made using the current DSM-IV, and thus, we will still be using the terms Autistic Disorder, Asperger’s Disorder, and PDD-NOS.   It is advisable for clinicians/diagnosticians to commence using both sets of terminology so as to minimize confusion in the future.  Sharing a document such as this one with the parents of the newly diagnosed is also advised.


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