Over time, the DSM has changed radically; the concept of an "autism spectrum" is relatively recent, and major changes to criteria for autism diagnoses will change what we presently think of as the "autism world." The two most significant changes will be the removal of two existing autism spectrum diagnoses - PDD-NOS and Asperger syndrome - from the manual.
To find out more about the proposed changes, I contacted the APA and posed a number of questions. After a few weeks, I received responses, most written by Dr. Bryan King of the Neurodevelopmental Disorders workgroup.
BackgroundThe new DSM 5 criteria as proposed include a number of new disorders such as social communication disorder, which seems to include symptoms that are now included within the autism spectrum. Here are the criteria for that proposed new diagnosis:
A. Social Communication Disorder (SCD) is an impairment of pragmatics and is diagnosed based on difficulty in the social uses of verbal and nonverbal communication in naturalistic contexts, which affects the development of social relationships and discourse comprehension and cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability.
B. The low social communication abilities result in functional limitations in effective communication, social participation, academic achievement or occupational performance, alone or in any combination.
C. Rule out Autism Spectrum Disorder (ASD). ASD by definition encompasses pragmatic communication problems, but also includes restricted, repetitive patterns of behavior, interests or activities as part of the autism spectrum. Therefore, ASD needs to be ruled out for SCD to be diagnosed.
D. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities).
My QuestionBased on the criteria in the proposed version of the DSM 5, it looks like the focus will be on stereotyped and repetitive behaviors, and that other related symptoms are being broken off into new and/or different categories. It also looks like a child could easily wind up with multiple diagnoses.
For example, a child with social and communications difficulties (which presumably could include lack of eye contact, etc.) could presently fit into the PDD-NOS category, with or without "the presence of repetitive behaviors and restricted interests." Would the new criteria mean they'd be recategorized OUT of ASD and into the new SCD?
Response from the APAStereotyped and repetitive behaviors and unusual preoccupations or interests have been essential criteria for the diagnosis of autism from its earliest descriptions. In the changes proposed in DSM 5, the focus on stereotyped behaviors isn't really changing. However, there is a desire to be able to more precisely describe individuals diagnostically than is currently possible with DSM-IV, and in some cases this may involve using more than one diagnosis.
For example, by pulling language impairment out of the diagnostic criteria for autism, we will be able to better describe individuals with autism with or without significant language impairment, as opposed to giving them the same diagnosis. Similarly, the DSM-IV prevents the co-diagnoses of ADHD and autism, or of schizophrenia and autism. But we know that these conditions can co-occur, and DSM 5 will allow for this ability to better capture what is at issue for a given individual than merely "autistic disorder".
Furthermore, PDD-NOS does not have associated diagnostic criteria, as it was originally intended to be used only sparingly for children who didn’t meet criteria for autism or Asperger disorder. Because DSM-IV didn’t have a diagnostic category for children with social communication difficulties only, these children were often given a diagnosis of PDD-NOS. This was not equivalent to a diagnosis of autistic disorder, because it encompassed other developmental disorders as well. The new criteria could re-classify children whose deficits are limited to social communication (and who therefore are not part of the autism spectrum), as well as others, by broadening inclusion in the autism spectrum. The new criteria could also provide for more specific and accurate social communication diagnoses, potentially leading to more appropriate treatment.
More answers to questions about the DSM 5