Ari's Omission : Autistic Disorder and Aspergers Disorder are Critically Different Disorders

Why do some persons with Aspergers Disorder insist on the right to speak for persons with Autistic Disorder, to tell the world that persons with Autistic Disorder do not want to be cured, and why does the media let them get away with it?

Newsweek has now become the latest stop for Ari Ne'eman, a very intelligent, highly articulate gentleman with Aspergers who persistently purports to speak on behalf of all people with "autism". Ne'eman, with Aspergers Disorder, expresses his opinion, as a person with "autism", about what is good for children with Autistic Disorder a related but distinct Disorder in the Pervasive Developmental Disorder category of the DSM-IV. One of his central themes which he delivers on behalf of persons with autism is "we don't want to be cured". Good for the intelligent, articulate Ari Ne'eman but does he have the right to make that claim on behalf of persons with Autistic Disorder with communication deficits and in many cases cognitive impairment people, including children with whom he has little in common?

Many children and adults with Autistic Disorder suffer from cognitive and communication deficits which seriously impair their ability to understand and function in the real world. Those with Aspergers Disorder like Ari Ne'eman do not have cognitive impairment or serious language impairment ... by definition.

DSM-IV Diagnostic Criteria for Aspergers Disorder and Autistic Disorder

The DSM (Diagnostic and Statistical Manual, American Psychiatric Association) diagnosis criteria for Aspergers Disorder expressly exclude impairments in cognitive AND communication development:

(IV) There is no clinically significant general delay in language (E.G. single words used by age 2 years, communicative phrases used by age 3 years)

(V) There is no clinically significant delay in cognitive development or in the development of age-appropriate self help skills, adaptive behavior (other than in social interaction) and curiosity about the environment in childhood.

The reality for many people with Autistic Disorder is much different when it comes to delays, some permanent, in cognitive development and language:

(B) qualitative impairments in communication as manifested by at least one of the following:

1. 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)

2. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others

3. stereotyped and repetitive use of language or idiosyncratic language

4. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

The DSM does not expressly state that cognitive development is a diagnostic criteria for autistic disorder but it is clearly implicit in the list of developmental deficits that cognitive deficits or mental retardation would be associated with these serious deficits in many cases.

ICD-10 Diagnostic Criteria for Aspergers Disorder and Autistic Disorder

The European equivalent of the DSM, the ICD-10 Classification of Mental and Behavioural Disorders states this obvious point expressly in distinguishing between Autistic Disorder and Aspergers Syndrome. Under the ICD-10 an Asperger's Syndrome diagnosis expressly excludes

Autistic Disorder

...

In addition to these specific diagnostic features, it is frequent for children with autism to show a range of other nonspecific problems such as fear/phobias, sleeping and eating disturbances, temper tantrums, and aggression. Self-injury (e.g. by wrist-biting) is fairly common, especially when there is associated severe mental retardation. Most individuals with autism lack spontaneity, initiative, and creativity in the organization of their leisure time and have difficulty applying conceptualizations in decision-making in work (even when the tasks themselves are well within their capacity). The specific manifestation of deficits characteristic of autism change as the children grow older, but the deficits continue into and through adult life with a broadly similar pattern of problems in socialization, communication, and interest patterns. Developmental abnormalities must have been present in the first 3 years for the diagnosis to be made, but the syndrome can be diagnosed in all age groups.

All levels of IQ can occur in association with autism, but there is significant mental retardation in some three-quarters of cases.

Includes:
* autistic disorder
* infantile autism
* infantile psychosis
* Kanner's syndrome

Asperger's Syndrome

A disorder of uncertain nosological validity, characterized by the same kind of qualitative abnormalities of reciprocal social interaction that typify autism, together with a restricted, stereotyped, repetitive repertoire of interests and activities. The disorder differs from autism primarily in that there is no general delay or retardation in language or in cognitive development. Most individuals are of normal general intelligence but it is common for them to be markedly clumsy; the condition occurs predominately in boys (in a ratio of about eight boys to one girl). It seems highly likely that at least some cases represent mild varieties of autism, but it is uncertain whether or not that is so for all. There is a strong tendency for the abnormalities to persist into adolescence and adult life and it seems that they represent individual characteristics that are not greatly affected by environmental influences. Psychotic episodes occasionally occur in early adult life.

Diagnostic Guidelines

Diagnosis is based on the combination of a lack of any clinically significant general delay in language or cognitive development plus, as with autism, the presence of qualitative deficiencies in reciprocal social interaction and restricted, repetitive, stereotyped patterns of behaviour, interests, and activities. There may or may not be problems in communication similar to those associated with autism, but significant language retardation would rule out the diagnosis.

Includes:

* autistic psychopathy
* schizoid disorder of childhood

In both the DSM and the ICD manuals Aspergers and Autistic disorders are distinct with Aspergers expressly excluding general delay in cognitive and communication development. These distinctions should be made clearer in the DSM V revision and separated from the same "spectrum" that has caused so much misunderstanding.

Ari Ne'eman a very intelligent, highly articulate gentleman with Asperger's Disorder has every right to speak on his own behalf and on behalf of those persons with Aspergers who agree with his views. Mr. Ne'eman has no right to suggest that persons with Aspergers and persons with Autistic Disorder are fundamentally similar. They differ by definition in the critically important areas of cognitive and language development. Ari Ne'eman does not have these deficits and can not begin to appreciate the challenges that having those deficits brings to the lives of persons, like my son Conor, who has an Autistic Disorder diagnosis and is assessed with profound developmental delays.

Aspergers includes social impairment. Autistic Disorder includes social impairment but also includes substantial delays and deficits in language impairment and, in many cases, cognitive development. It is hard to imagine any two areas, communication and cognitive functioning, any more important to daily life. And yet, despite these two critically important differences they are not separated clearly enough as disorders in the DSM. The result is widespread public confusion and misguided advocacy.

The impending DSM-V should do everyone a favor and separate more clearly these two disorders with fundamentally different diagnostic criteria in areas central to any human existence - communication and intelligence.

autism