Autism

How Will DSM-5’s Revisions Affect Children With Autism?

JOHN W. HARRINGTON, MD

 

Pediatrics Update

The American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) on May 22, 2013. It replaces the fourth edition, text revision (DSM-IV-TR), published in 2000 as an update to the DSM-IV, which was published in 1994.
Changes to the diagnostic criteria for autism have been made in the DSM-5 based on a painstaking review of the literature by researchers and experts in the field as well as on comments submitted by health professionals, patients, families, and advocates for those with autism. The revisions have been made with the hope that the diagnosis of autism spectrum disorders (ASD) will be more specific, reliable, and valid.

Despite these positive hopes, concerns have been raised about how these changes to the diagnostic critera might impact people who currently have a diagnosis of ASD and people who will receive an ASD diagnosis in the future. One concern is that people who are higher-functioning no longer will meet the DSM-5’s stricter diagnostic criteria for ASD and therefore might have difficulties accessing relevant health care services. Furthermore, there is uncertainty about how state and educational services and insurance companies will adopt the changes in the DSM-5.

The main changes and clarifications in the DSM-5 are the following:

• Children with an appropriate diagnosis of “autistic disorder,” “pervasive developmental disorder not otherwise specified” (PDD-NOS), “Asperger’s disorder,” and “childhood disintegrative disorder” will now meet the criteria for the diagnosis of ASD. Therefore, it is unlikely that children with a current diagnosis of autism will “lose” their diagnosis; however, the new DSM-5 criteria should affect children suspected of having ASD who are entering the initial diagnostic phase.

• The triad of core domain categories found in the DSM-IV (impairment in social interaction, impairment in communication, and repetitive and restrictive behaviors) have become a dyad of core domains in the DSM-5 (deficits in social communication and social interaction combined, with 3 of 3 required criteria; and repetitive/restrictive behaviors, interests, and activities, with 2 of 4 required criteria).

• Within the repetitive/restrictive behaviors criteria, the presence of unusual sensory behaviors has been added to include such characteristics as indifference to pain, excessive smelling of objects, and visual perseveration of lights.

• ASD now will have 3 levels of severity based on the amount of support required (level 1 entails support, level 2 entails substantial support, and level 3 entails very substantial support). This support will be scored separately in the 2 core domains (deficits in social communication and social interaction combined, and repetitive/restrictive behaviors, interests, and activities). It is understood that the severity rating may vary in different social situations and might change over time.

• The DSM-5 allows a dual diagnosis of ASD and attention-deficit/hyperactivity disorder.

• Specifiers can be used to clarify whether a comorbid diagnosis of language and/or intellectual impairment exists in a patient. However, in order to diagnose intellectual impairment or disability and ASD together, the person’s social communication level must be below the overall expected developmental level.

• Social (pragmatic) communication disorder (SCD) is a new condition that does not meet the criteria for ASD because it lacks the presence of repetitive and restrictive behaviors. Some children who initially had been diagnosed with PDD-NOS or Asperger disorder may fit this diagnosis better.

Incorporating these changes into everyday practice may seem daunting at first, but the authors of the DSM-5 have tried to make the ASD diagnosis less arbitrary by adding the use of specifiers and by providing specific descriptions of behaviors directly in the criteria. It remains to be seen whether this will have any effect on the overall prevalence of autism, which now stands at 1 in 50 children,1 and whether it will have any impact on the availability of services through educational systems and insurance companies.

Reference:

1. Blumberg SJ, Bramlett MD, Kogan MD, Schieve LA, Jones JR, Lu MC. Changes in prevalence of parent-reported autism spectrum disorder in school-aged U.S. children: 2007 to 2011–2012. National Health Statistics Reports. March 20, 2013; 65. http://www.cdc.gov/nchs/data/nhsr/nhsr065.pdf. Accessed July 5, 2013.