News | Mind & Brain
Experts call for small and easy changes to the Diagnostic
and Statistical Manual, the "bible" of psychiatry, so that
everyone with autism spectrum disorder qualifies for a
diagnosis
By Ferris
Jabr | January 30,
2012 |
DIAGNOSING THE DSM: The
DSM-5 should sharpen the definition of autism, if the
American Psychiatric Association makes a few tweaks in
time Image: UrsaHoogle,
iStockphoto
People have been arguing about autism for a long time—about
what causes it, how to treat it and whether it qualifies as
a mental disorder. The
controversial idea that childhood vaccines trigger autism also
persists, despite the fact that
study after study has failed to find any evidence of such a
link. Now, psychiatrists and members of the autistic community
are embroiled in a more legitimate kerfuffle that centers on
the definition of autism and how clinicians diagnose the
disorder. The debate is not pointless semantics. In many cases,
the type and number of symptoms clinicians look for when
diagnosing autism determines how easy or difficult it is for
autistic people to access medical, social and educational
services.
The controversy remains front and center because the American
Psychiatric Association (APA) has almost finished redefining
autism, along with all other mental disorders, in an overhaul
of a hefty tome dubbed the Diagnostic and Statistical
Manual of Mental Disorders (DSM)—the essential reference
guide that clinicians use when evaluating their patients. The
newest edition of the manual, the DSM-5, is slated for
publication in May 2013. Psychiatrists and parents have voiced
concerns that the new definition of autism in the DSM-5 will
exclude many people from both a diagnosis and state services
that depend on a diagnosis.
The devilish confusion is in the details. When the APA
publishes the DSM-5, people who have already met the criteria
for autism in the current DSM-IV will not suddenly lose their
current diagnosis as some parents have feared, nor will they
lose state services. But several studies recently published in
child psychiatry journals suggest that it will be more
difficult for new generations of high-functioning autistic
people to receive a diagnosis because the DSM-5 criteria are
too strict. Together, the studies conclude that the major
changes to the definition of autism in the DSM-5 are well
grounded in research and that the new criteria are more
accurate than the current DSM-IV criteria. But in its efforts
to make diagnosis more accurate, the APA may have raised the
bar for autism a little too high, neglecting autistic people
whose symptoms are not as severe as others. The studies also
point out, however, that minor tweaks to the DSM-5 criteria
would make a big difference, bringing autistic people with
milder symptoms or sets of symptoms that differ from classic
autism back into the spectrum
A new chapter
Autism is a disorder in which a child's brain does not develop
typically, and neurons form connections in unusual ways. The
major features of autism are impaired social interaction and
communication—such as delayed language development, avoiding
eye-contact and difficulty making friends—as well as restricted
and repetitive behavior, such as repeatedly making the same
sound or intense fascination with a particular toy.
The DSM-5 subsumes autistic disorder, Asperger's disorder,
childhood disintegrative disorder, and pervasive developmental
disorder not otherwise specified (PDD-NOS)—which are all
distinct disorders in DSM-IV—into one category called autism
spectrum disorder (ASD). The idea is that these conditions have
such similar symptoms that they do not belong in separate
categories, but instead fall on the same continuum.
Essentially, to qualify for a diagnosis of
autistic disorder in DSM-IV, a patient must show at least
six of 12 symptoms, which are divided into three groups:
deficits in social interaction; deficits in communication; and
repetitive and restricted behaviors and interests. In contrast,
the DSM-5 divides seven symptoms of ASD into two main
groups: deficits in social communication and social
interaction; and restricted, repetitive behaviors and
interests. (For a closer look at the changes, read the
companion piece: "Autism
Is Not a Math Problem". You can also compare DSM-IV and
DSM-5 criteria for autism on the
APA's Web site.)
The APA collapsed the social interaction and communication
groups from DSM-IV into one group in the new edition because
research in the last decade has shown that the symptoms in these
groups almost always
appear together. Research and clinical experience has also
established that heightened or dulled sensitivity to sensory
experiences is a core feature of autism, which is why it
appears in DSM-5 but not in the preceding version. The
psychiatric community has generally applauded these changes to
the criteria for ASD.
What is in question is how many of the DSM-5 criteria a patient
must meet to receive a diagnosis—too many and the manual
excludes autistic people with fewer or milder symptoms; too few
and it assigns autism to people who don't have it. Since the
1980s the prevalence of autism has dramatically increased
worldwide, especially in the U.S. where the Centers for Disease
Control and Prevention estimates that nine per 1,000 children
have been diagnosed with ASD. Many psychiatrists agree that the
increase is at least partially explained by loose criteria in
DSM-IV.
"If the DSM-IV criteria are taken too literally, anybody in the
world could qualify for Asperger's or PDD-NOS," says Catherine
Lord, one of the members of the APA's DSM-5 Development
Neurodevelopmental Disorders Work Group. "The specificity is
terrible. We need to make sure the criteria are not pulling in
kids who do not have these disorders."
Continued here:
Redefining Autism: Will New DSM-5 Criteria for ASD Exclude Some People?