Comments on the DSM-5 Autism Spectrum criteria
Posted by in UncategorizedPeople often ask about the new definition of Autism Spectrum Disorders (ASD) to be released with the DSM-5. They are concerned about restricting the diagnosis and about Asperger Syndrome and PDDNOS disappearing as diagnoses and if their child may no longer qualify for services.
I have been to several presentations on the new criteria, including some with some of the authors. I think the new system makes sense. It collapses the social deficits and communication deficits into one area, because they are so intertwined. They then add sensory processing problems to the Repetitive Behaviors area. Adding this makes all sorts of sense. While you can have sensory problems without having an ASD, nearly everyone with an ASD has sensory processing problems. So everyone will have the same diagnosis – Autism Spectrum Disorder. Then a severity level will be assigned ”support needed, significant support needed, and full support needed. This is not the same as “mild, moderate, severe”. It is to indicate the level of support needed by the person to live as independently as possible. Any child should automatically have at least “significant” support needed, because they are children! They need support for feeding, shelter, daily care, education, etc, just as any chid does. Then a qualifier will be added. Some may be “associated with epilepsy”, “associated with language regression at 24 months”, or “associated with Fragile X”. I suspect for those currently diagnosed with Asperger Syndrome, it may be “associated with the pattern of strengths and weaknesses associated with Asperger Syndrome”.
What about adults? By definition, it is a disorder if it interferes with some life domain – work, community, home. If it isn’t – it is not a disorder. If it does, then some level of support is needed. Nobody diagnosed with Asperger Syndrome should lose the diagnosis if they need support. If they don’t need support, do they have a disorder?
I predict the new criteria will still be variably applied, depending on the clinician making the diagnosis. People whose experience is more with severely affected people will still be reluctant to diagnosis higher functioning people, but those who are used to seeing the higher functioning people will continue to diagnose them. There will still be controversy, there will still be debate, and there will still be disagreement over how to apply the criteria. What should not change is people with ASD getting the services they need, regardless of severity or age.
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What about age criteria? Is it 3 years across the board? Asperger’s Syndrome s typically not diagnosed or evident til later – will they lose out on support because they appeared more typical prior to social demands being placed on them??
I don’t believe there is a requirement for sx before 3, but even kids with Asperger Syndrome usually have symptoms at young ages, even if they were not recognized as being unusual.
Thank you for sharing your insight. An esteemed colleague is part of the medical committee evaluating the new criteria. The question that it poses is what happens to young adults who present initially as Aspergers who are no longer considered to require support. In my clinical experience family and community support is often intricately intertwined in day to day life such that the individual with a diagnosis is indeed quite functional and the family system may not fully realize how well they have set up systems to support the individual. In the absence however of those familiar support systems the individual is not as successful. This has implications for community supports and financial assistance. Will they lose the diagnosis and then if unsuccessful in life get the diagnosis back?
I don’t know how it will all play out. However, I think if families are that involved day to day, then the person still requires enough support to warrant the diagnosis.