Sunday, July 24, 2011

DSM-5 Autism Shell Game

Noun1.shell game - a swindling sleight-of-hand gamevictim guesses which of three things a pellet is under
Synonyms: thimblerig

The DSM-5 treatment of autism amounts to little more than a shell game with autism, which once referred essentially to autistic disorder being replaced with Asperger's Disorder.  Look at the description of A 09 Autism Spectrum Disorder in the DSM-5 which is referred to in the DSM-5 as a proposed revision for the DSM-IV Autistic Disorder:


A click on the DSM-5 A 09 Autism Spectrum Disorder tab for DSM-IV refers the reader to Autistic Disorder as set out in the DSM-IV leading one to think that the new Autism Spectrum Disorder is in fact just a modified version of the DSM-IV's Autistic Disorder:


The most obvious difference is in paragraph 2 which refers in the introductory line to qualitative impairments in communication. One of the sub-paragraphs which assists in fulfilling that requirement for meeting an Autistic Disorder is "delay in or total lack of the development of spoken language".  The narrowing of communication deficits from general communication deficits to social communication deficits is not just a revision, it is a re-definition of autistic disorder.  Removing this important characteristic from "autism" constitutes an essential change from Autistic Disorder, at least from the perspective of this father of a son with autistic disorder who has had both delays in language development and a lack of full language development.

As can be seen in the DSM-IV description of Asperger's Disorder removing any reference to general language delay or development renders the new Autism Spectrum Disorder much more like the DSM-IV description of Asperger's Disorder which states in paragraph D that there is no clinically significant general delay in language. The only reference to language deficit in the new ASD is in the reference to social communication, a specific not general language deficits. Again, I am a humble parent and small town lawyer not an Ivy League educated psychologist or psychiatrist but I have to assume that language and general communication developments are among the most fundamental aspects of any human's development. To remove the general language and communication deficits from Autistic Disorder and substitute social communication deficits appears to me to be a straight forward substitution of Aspergers for Autistic Disorder in defining the New Autism Spectrum Disorder in the DSM-5.


Consistent with substitution of Asperger's Disorder for Autistic Disorder is the exclusion of persons from Autism Spectrum Disorder diagnosis where the mandatory social communication and social interaction deficits required under criterion A are "accounted for by general developmental delay". I have commented on this exclusion several times and I see no other reasonable interpretation of the exclusionary language in Criterion A of the new Autism Spectrum Disorder. Criterion A effectively brings to the DSM-5's new Autism Spectrum Disorder criteria D and E of the DSM-IV's Asperger's Disorder description ... no clinically signficant delay in language and no clinically signficant delay in cognitive development.

A reasonable interpretation of the DSM-5's new Autism Spectrum Disorder is that it essentially substitutes Asperger's Disorder for Autistic Disorder. Asperger's Disorder IS the New Autism Spectrum Disorder of the DSM-5.  The language of the DSM-5 which purports to show Autism Spectrum Disorder as a revision of the DSM-IV's Autistic Disorder is misleading, whether intentional or not, and it helps conceal  under which shell the "autism pellet",  in the new DSM-5 is located. The DSM-5 new Autism Spectrum Disorder is located under the DSM-IV's Asperger's Disorder. 

The DSM-5's new Autism Spectrum Disorder is no more than a glorified shell game with low functioning, intellectually disabled autistic persons and their families the unwitting victims. The new Autism Spectrum Disorder would be more accurately described as Asperger's Spectrum Disorder with the many severely affected, low functioning, intellectually disabled autistcs of the DSM-IV excluded.. 

7 comments:

Luna said...

I'm not sure I understand your point. How do low functioning autistic people get left behind in this? How would they be excluded from diagnosis?

Myself, I'm more concerned that the way that girls present with ASD is completely left out. Again. The anxiety component, for example, is completely missing.

Autism Reality NB said...

Luna, I have mentioned how low functioning autistic people are excluded from the DSM5 New Autism Spectrum Disorder in earlier posts.

Low functioning autistic people are left behind because all 4 criteria for a definition of Autism Spectrum Disorder MUST be present before an Autism Spectrum Disorder will be given.

Criterion A of the new ASD excludes an ASD diagnosis in cases where social communication and social interaction deficits are "accounted for by general developmental delay". This wording removes those with what we now call intellectual disability from the autism spectrum and moves them to the DSM-5's new A00 Intellectual Developmental Disorder which in paragraph B states:

B. The deficits in general mental abilities impairs functioning in .......... one or more aspects of daily life activities such as communication, participation in social activities, ...

While the DSM Autism Spectrum Disorder is described as a revision of Autistic Disorder it is not. It is a revision of Aspergers Disorder. The 80% of persons with DSM IV Autistic Disorder and intellectual disabilities will now be moved to a different shell ... to the DSM5's new A00 Intellectual Developmental Disorder.

farmwifetwo said...

Whereas my youngest would qualify for the dx since his attempts to communicate, learn, grow etc are obviously impaired by the autism itself. His gains in learning and speech in the last year have been significant and leave us wondering what he does or does not know.

But those with less of an ability to non-verbal or not at all communicate and no significant growth in speech over the years, would automatically be ID.

This is your fear??? Not dismissing it.... simply trying to figure it out incase it ever becomes an issue.

Rachel said...

I have Asperger's, and I understand and share your concerns about the new criteria. There is a huge difference between my difficulties with social communication and the difficulties of someone with little-to-no spoken language. I mean, you don't have to have a PhD to understand that -- just an ability to observe what's going on around you and draw appropriate conclusions. Rocket science, this ain't.

And tossing out autistic people with ID is also very, very troubling, to put it mildly.

If those writing the DSM-V criteria want to put all of us under the same umbrella, the least they could do is to be accurate about the huge differences in the capabilities and needs of people under that umbrella. What they're done, in my view, is a major overreaction to what happened in the past. Before 1994, people like me got no diagnosis, despite the fact that having one would have been an enormous help in a myriad of ways. But now, people like your son, with much more profound challenges, will get no diagnosis at all, despite needs that go far beyond anything I've ever experienced.

That's not progress. It's just substituting one wrong for another.

Luna said...

Ahh! Okay, now I understand. Sorry, there are days and there are days... Ya know? :)

Anonymous said...

As someone who has a child with a language disorder, I welcome this change. Children with language disorders today are almost automatically assumed to be autistic by the schools and undereducated doctors. It's hard to get children the language-focused education they need, because the schools just want to slap an autism label on them, segregate them in an autism program, and treat them with a program that's not appropriate. Been there, done that! It was a disaster.

Autism is not a language disorder, and pulling that out should help identify true autism from other disorders.

Rachel said...

Anonymous, I'm not quite sure I understand... There are many other criteria for autism than language issues, and a person has to meet them for a diagnosis. If people are slapping on autism labels for people who just have language disorders, that's the fault of the clinicians, not the fault of the criteria.

The problem with soft-pedaling little-to-no speech as a difficulty in "social communication" is that the diagnosis exists largely for the purpose of getting appropriate services. If the criteria specify social communication instead of a low or nonexistent ability to use spoken language, then programs will start getting tailored to people like me and not to people like Mr. Doherty's son.

No one should be left out. The range of services needs to get wider, not more narrow.