In May of 2013 the new diagnostic criteria for Autism Spectrum Disorder will be distributed to doctors via the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5). Think of the DSM 5 as the Bible of diagnostic criteria, developed and written by the American Psychiatric Association (APA).
One of the most discussed changes in the DSM 5 Autism Spectrum Disorder (ASD) is the removal of Asperger’s syndrome and PDD-NOS as individual diagnoses. Under the new diagnostic criteria, Asperger’s and PDD-NOS will come under the umbrella of ASD. For example a child whose diagnosis is currently Asperger’s syndrome would receive a new diagnosis of Autism Spectrum Disorder with specifiers included, such as “Autism Spectrum Disorder with fluent speech” or “Autism Spectrum Disorder with intellectual disability”. According to Dr. Bryan King, of the APA’s Neurodevelopmental Disorders Workgroup, this change could mean a decrease in the differentiation of services available to those previously diagnosed with Asperger’s syndrome. (http://autism.about.com/od/diagnosingautism/a/Why-Asperger-Syndrome-Will-Disappear.htm) In layman’s terms this means that some children will benefit from a greater availability of needed services because they have a diagnosis of ASD, rather than Asperger’s.
Another change between current DSM IV standards and the proposed DSM 5 criteria for a diagnosis of Autism Spectrum Disorder is the requirement that a child MUST exhibit symptoms from EVERY area of the DSM diagnostic criteria. There are four areas of impairment set forth in the DSM 5 (http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=94# - Proposed Revision tab):
A. 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. 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.
The difference in criteria lays in the fact that a child will have to show symptoms in EVERY area above to receive a diagnosis of Autism Spectrum Disorder. Look carefully at the current DSM IV diagnostic criteria (http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=94# – DSM IV tab) and you will notice the increase in specificity of symptoms and areas of impairment(s) required for an ASD diagnosis:
A. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3)
(1) qualitative impairment in social interaction, as manifested by at least two of the following:
(a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
(b) failure to develop peer relationships appropriate to developmental level
(c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
(d) lack of social or emotional reciprocity
(2) qualitative impairments in communication as manifested by at least one of the following:
(a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
(b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
(c) stereotyped and repetitive use of language or idiosyncratic language
(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
(3) restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following:
(a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
(b) apparently inflexible adherence to specific, nonfunctional routines or rituals
(c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
(d) persistent preoccupation with parts of objects
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play
C. The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder.
In addition to the revised diagnostic criteria, the AAP has included a three level Severity scale for ASD. This scale will be used as a guide for determining the amount of services needed by an individual with an ASD. A copy of the scale can be found by clicking the Severity tab on the APA DSM 5 Proposed Changes webpage. (http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=94# – Severity tab)
The overriding concern is what these changes mean for students receiving autism services through their IEP. For students who currently have an IEP due to a diagnosis of Asperger’s syndrome, it seems as though a change in services would be unlikely, except for the possibly of the addition of services for previously unmet needs.
The situation for a student with a current (DSM IV criteria) based autism diagnosis may be vastly different. Children who do not exhibit significant difficulty with sensory or perseverative issues could be diagnosed with a Social Communication Disorder, and not an ASD. If a student is recategorized using the DSM 5 criteria for an ASD, then he or she could be denied access to services such as Occupational Therapy or Physical Therapy which they have received through their IEP in past years.
Parents, caregivers and special education advocates must become knowledgeable about the proposed diagnostic revisions for Autism Spectrum Disorder and the possible effects on students receiving autism related services. It is imperative that attention is given to the APA’s development of ASD secondary feature definitions and the specific qualifiers that will be attached to an autism diagnosis as well. Becoming informed and educated about these changes and additions is necessary in order to be your student’s best, most effective educational and medical advocate.
Lee Anne Owens is the mother of five children ages 6 to 14. Her blog, Swimmin’ in Alphabet Soup (http://swimmininalphabetsoup.blogspot.com/), is a humorous and truthful journal about mothering children with various neurological impairments including Autism Spectrum disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD), Obsessive Compulsive Disorder (OCD) and mild learning disability. Lee Anne is a certified parent support volunteer with INSource Indiana and is currently completing course work to become a certified Case Conference Advocate for special needs students.