Saturday, January 29, 2011

Criteria D in the DSM-5's New Autism Spectrum Disorder: Limited and Impaired Everyday Functioning

With the  January 26, 2011, revision of the  new Autism Spectrum Disorder category in the DSM-5 will some high functioning persons who currently have an Autism or Aspergers diagnosis  actually lose their autism diagnosis because they do not meet  criteria D,"limited and impaired daily functioning", of the 4 ASD mandatory criteria?

"299.00 Autistic Disorder                   Revised January 26, 2011

Autism Spectrum Disorder
Must meet criteria A, B, C, and D:
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."

Will some well known, self described, autism self advocates lose their autism diagnosis when the DSM-5 is published?  Can persons capable of raising a family, performing in rock bands,  driving land rovers, running  successful businesses, serving on the boards and committees of organizations such as ASAN, Autism Speaks and the IACC, graduating with university degrees, appearing before high appellate courts and government committees, publishing books, conducting research, and appearing in print and broadcast media interviews truly be considered to be limited and impaired in their everyday functioning? Will ANY members of the ASAN Board of Directors be considered to be limited and impaired in their everyday functioning?

Look for some intense reaction to the limited and impaired everyday functioning requirement.  Do not be surprised to see a high pressure campaign to eliminate criteria D.


AutisticWisdom said...

Harold you are probably right but even most people with Asperger's have impaired adaptive functioning in social interaction and language pragmatics. People who don't have even that aren't really autistic.

John Best said...

The fake Asperger's victims will still be considered impaired since no rational person would celebrate having autism and all rational people favor curing those with any form of autism. When employers see how crazy these people act, it certainly limits their opportunities.

Anonymous said...

I agree that some will probably lose their diagnosis, but many self-advocates do have serious impairments in daily living. I am an example, but I know of self-advocates who on the surface lead normal lives, but still have a mild impairment in daily living. For example, tehy may not be able to do household skills without assistance, but can hold jobs that match their special interests. By the way, DSM-IV already has a criterion that says people must be significantly impaired in social, occupational or other areas of functioning. I wonde rhow similar this criterion D is to the existing criterion.

Anonymous said...

"mild impairment in daily living. "

The DSM V doesn't include mild impairment. It has to be significant.

I suspect that so called "self advocates" will simply frame their self diagnosis to fit with the new DSM. We're talking about people with personality disorders here. If the DSM V said they had to have epilepsy to have autism, soon they would be feigning epileptic seizures. If the DSM V said they had to have a missing left arm then that might cause a problem, unless of course they adopted the devotee extremism of those who chop off their own limbs in order to be "accepted" in the amputee "community". Yes, people actually cut off their own limbs to become amputees because of a fetish.

What is most important is the severity category, which seems to exclude people in the self advocacy realm.

Autism Mom said...

I've met parents who believe wholeheartedly that because their child isn't a social butterfly that this alone is equivalent to a severe and life altering impairment. It's very sad that these children are viewed as impaired but only in the eyes of their parents who continually have to point this out to the average onlooker who sees nothing but a normal, healthy child.

Anonymous said...

I completely disagree with criteria D. For a diagnosis of blindness, is it required that you have "impaired everyday functioning"? If someone who is blind adapts very well, gets a job, gets a seeing eye dog, and functions better than some sighted people, are they no longer blind?

Whether you have something, and how well you do or do not cope with it, are completely separate and distinct issues, in my humble opinion.

Chris M.

Unknown said...

Chris M, if a person suffers no significant impairment in their functioning level why should they receive a mental disorder diagnosis of Autism Spectrum DISORDER?

layla said...

My son has autism, is 4, and has had intensive in home ABA 40 hrs a week therapy since he was 1 1/2, but is now getting less due to his gains. He now looks indistinguishable from his peers to the untrained eye, but to the trained eye, we can see his fixations, lack of eye contact at times, stims, repetitive language, lack of play skills,etc, etc, etc... He came from no language, no eye contact, flat facial affect, only spun wheels and fixated on circular things constantly, and no responses.

Today, he still fits every criteria for the autism diagnosis even after his great successes, and if he didn't continue to receive therapy (or maintenance of those skills once he no longer needs his therapy, which is projected within several months time), we would lose a lot of skills, and he would become more severe in his autism.

My son looks indistinguishable and can carry on a pretty good conversation, but the function of many of his decisions are different than the function (reason) of his typical peers.

The gap is getting smaller between him and his typical peers, and his defecits are smaller and smaller. He will probably marry, raise a family and hold a great job someday, and move off the spectrum. And he should.

It's not fair to others who have autism more severely to not acknowledge their autism is different than my son's (whose brain was able to change at a young age due to his ABA and other therapy). My son will be quirky and still love circles and spinning (physics professor maybe?)in a couple years, but he should not be claiming to understand the complexities other people with autism still live with (the very things he COULD claim if his brain connections were not able to change due to his ABA therapy at such a young age). The world will be different for him had he not received the therapy he received at the age he did. It changed his brain.

He will be able to claim he has some quirks that effect him in various ways, and he has a history of having a neurological condition when he was young which he overcame with therapy; and people who have autism will be able to claim they have autism, and it affects their life in almost every way imaginable. He will probably recall how some things felt for him when he met all the criteria for autism.

And the world will be a little different to him had his brain not experienced autism during his early years.

Anonymous said...

An impaired functioning of a person's eyes (blindness) does not necessarily translate into an impaired functioning of that person in society. Does that mean they are not blind after all? Does that mean they do not need accomodations?

An impaired functioning of a person's social abilities (high functioning autism) does not necessariliy translate into an impaired functioning of that person in society. Does that mean they are not on the autism spectrum? Does that mean they do not need accomodations in order to succeed?

The answers seem obvious to me. Impairements in specific areas do not HAVE to lead to impaired functioning, provided impairements in specific areas are recognized and accomodated.

Compensations are made. Impairements are still very much present. No one should forget this, or well functioning blind people will be expected to "see" and those of us who are high functioning will be expected to do things we are not capable of.

Chris M.

Kate said...

Harold, most of the things you list as examples of ability to function (publishing books, playing in bands, etc.) can't be considered as basic everyday tasks. I'm autistic, and I'm considered very gifted verbally - I could read before I could speak, and I learn foreign languages extremely quickly. I studied at Oxford University. But this doesn't make me able to cook safely by myself or to go to the supermarket and buy things alone. It doesn't make me able to recognise danger or give me the skills I need to cope with sudden changes to my routine in a safe manner. Intellectually I'm very capable, but intellect isn't everything. I live semi-independently, with four hours of formal outreach support each day and a lot of help from my family. It bothers me when people assume that my university degree cancels out the problems I have with everyday tasks.