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Autism Spectrum Disorder and the DSM-5
In May 2013, the American Psychiatric Association (APA) released the latest version of the Diagnostic and Statistical Manual of Mental Disorders, known as the DSM-5. The manual included several diagnostic changes to the definition of autism spectrum disorder and also added somewhat controversial criteria for a new disorder known as Social (Pragmatic) Communication Disorder. The major changes between the DSM-IV and the DSM-5 were discussed in our blog, DSM-IV vs DSM- 5: What has Changed?. Below a more detailed report on the diagnostic changes of the DSM-5, beginning with a transcription of the major changes to autism spectrum disorder as quoted by Susan E. Swedo1, Chair of the DSM-5 Nuerodevelopmental Disorders Work Group:
In DSM-5 we have made three major changes to autism from DSM-IV. The first of these is a merging of the independent diagnoses of autistic disorder, Asperger disorder, and pervasive developmental disorder into a single spectrum disorder: Autism Spectrum Disorder. Within that we have eliminated childhood disintegrative disorder on the basis that it was not being used as a diagnosis and more importantly we have added a specifier age of onset, which allows a clinician to diagnosis autism spectrum disorder with a later age of onset, typically after three years of age. The second major change in autism is the move from three criteria to two. This was done by combining the social and communication criteria of DSM-IV into a single criterion social communication or social reciprocity, which is the main feature of autistic spectrum disorder. Within autism spectrum disorder, the social communication deficits are impairing and lifelong persistent. The second criterion is restrict or repetitive behaviors and in that one some patients, actually through training or developmental progress, may have less obvious manifestations of RBs during adolescence and adulthood so that criterion can be met on the basis of history alone. The third major change to the autistic disorders I have already mentioned, and that is the inclusion of a number of specifiers. We expect clinicians to assign a primary diagnosis of autism spectrum disorder, but then to provide a very rich degree of information about that individual patient’s onset and clinical course by the use of descriptors for age of onset, type of onset…is intellectual impairment present, is verbal impairment present, as well as what kind of disorders are associated. As we know, autism spectrum disorders frequently comorbid with intellectual disability it is also comorbid with anxiety disorders, ADHD, and, in the medical realm, epilepsy.
This presentation provides us with the major changes to the ASD diagnostic criteria, but there are more specific and minute changes as well. According to SafeMinds2, the following is the new diagnostic criteria for autism spectrum disorder:
Currently, or by history, must meet criteria A, B, C, and D:
A. All individuals must have or have had persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following:
1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction,
2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures.
3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people
B. All individuals must have or have had restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:
1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).
2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes).
3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).
C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)
D. Symptoms together limit and impair everyday functioning.
To help explain the designation of specifiers as part of ASD diagnosis we will turn to a video titled Autism Diagnosis Criteria in the DSM-V developed by Autism Live, which is a production by the Center for Autism and Related Disorders (CARD). In the video, Dr. Doreen Granpeesheh discusses the specifics of the DSM-5 criteria as it applies to autism spectrum disorder. The following text has been excerpted from the AutismLive production3 and describes how specifiers will be implemented:
ASD DSM-5 Diagnosis: Specifiers and Modifiers
- With the new criteria, if the child meets [the criteria] for ASD he/she will receive a diagnosis with the etiology as a specifier
- ASD with Rett Syndrome
- ASD with Fragile X
- OR with a modifier indicating another important factor
- ASD with tonic-clonic seizures
- ASD with intellectual disabilities
Further in the AutismLive production3, Dr. Granpeesheh further discusses the implications of specifiers and modifiers using the following examples:
- Early History is also specified
- Age of perceived onset
- Pattern of onset
- Loss of skills
- ASD with onset before 20 months and loss of words
- ASD with onset before 32 months and loss of social skills
- ASD with no clear onset and no loss
- ASD-Asperger’s type
- Age of perceived onset
Later in the video, Dr. Granpeesheh discusses the levels of severity that accompany an ASD diagnosis and explains their important through provide examples of each level. This portion of the video can be found here.
Click here for a description on the DSM-5 Severity Levels of Autism
Please visit our Forum page on the DSM- 5 to further discuss your experiences on the release of the DSM-5.