Friday, January 20, 2012

DSM-V Changes

       There is a lot of talk about the new definition of autism in the DSM in the media. Here's the thing not once has the media said what the "new" definition is. Which is what they like to do get people all worked up but never tell them what they are worked up over. Well here it is. I posted how it is written in the DSM-IV  and the proposed change for the DSM-V. Read it, it is almost the exact same definition just more streamlined. Yes the wording has changed a bit but it means the same thing.  I actually like the new severity scale. Having a child that's in the middle he never fit on the low-functioning or high-functioning scale now he has a place and I think this scale will actually HELP not hurt the ability to get resources for him in school.  
       I have talked to our neuropsychologist and asked how the changes will affect us. He thinks in most cases the changes will be for the better.  So lets all take a deep breath do our research talk to your doctors about your concerns. I think the media is getting everyone in a frenzy over nothing. MANY thing in the DSM-V are changing. The DSM-V goes through a overhaul every so often and things change they have too. Change is not a bad thing. We need to remember the APA is not out to get us, the insurance companies did not pay them to make these changes if they did half the things in the DSM would be gone. The APA is a peer reviewed association. Their changes are based on research. Now good or bad that's up to who is reviewing the science. Lets not put the cart before the horse.
How it is listed in the DSM-IV:

Autistic Disorder
A. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):
(1)  qualitative impairment in social interaction, as manifested by at least two of the following:
(a)  marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
(b)  failure to develop peer relationships appropriate to developmental level
(c)  a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
(d) lack of social or emotional reciprocity
(2)  qualitative impairments in communication as manifested by at least one of the following:
(a)  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)
(b)  in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
(c)  stereotyped and repetitive use of language or idiosyncratic language
(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
(3)  restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
(a)  encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
(b)  apparently inflexible adherence to specific, nonfunctional routines or rituals
(c)  stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole body movements)
(d) persistent preoccupation with parts of objects
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.
C. The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder.

Proposed revision:
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.
Rational for change:
New name for category, autism spectrum disorder, which includes autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. 
  • Differentiation of autism spectrum disorder from typical development and other "nonspectrum" disorders is done reliably and with validity; while distinctions among disorders have been found to be inconsistent over time, variable across sites and often associated with severity, language level or intelligence rather than features of the disorder.
  • Because autism is defined by a common set of behaviors, it is best represented as a single diagnostic category that is adapted to the individual’s clinical presentation by inclusion of clinical specifiers (e.g., severity, verbal abilities and others) and associated features (e.g., known genetic disorders, epilepsy, intellectual disability and others.) A single spectrum disorder is a better reflection of the state of knowledge about pathology and clinical presentation; previously, the criteria were equivalent to trying to “cleave meatloaf at the joints”.
Three domains become two:
1)     Social/communication deficits
2)     Fixated interests and repetitive behaviors
  • Deficits in communication and social behaviors are inseparable and more accurately considered as a single set of symptoms with contextual and environmental specificities
  • Delays in language are not unique nor universal in ASD and are more accurately considered as a factor that influences the clinical symptoms of ASD, rather than defining the ASD diagnosis
  • Requiring both criteria to be completely fulfilled improves specificity of diagnosis without impairing sensitivity
  • Providing examples for subdomains for a range of chronological ages and language levels increases sensitivity across severity levels from mild to more severe, while maintaining specificity with just two domains
  • Decision based on literature review, expert consultations, and workgroup discussions; confirmed by the results of secondary analyses of data from CPEA and STAART, University of Michigan, Simons Simplex Collection databases
Several social/communication criteria were merged and streamlined to clarify diagnostic requirements.
  • In DSM-IV, multiple criteria assess same symptom and therefore carry excessive weight in making diagnosis
  • Merging social and communication domains requires new approach to criteria
  • Secondary data analyses were conducted on social/communication symptoms to determine most sensitive and specific clusters of symptoms and criteria descriptions for a range of ages and language levels
Requiring two symptom manifestations for repetitive behavior and fixated interests improves specificity of the criterion without significant decrements in sensitivity. The necessity for multiple sources of information including skilled clinical observation and reports from parents/caregivers/teachers is highlighted by the need to meet a higher proportion of criteria.
The presence, via clinical observation and caregiver report, of a history of fixated interests, routines or rituals and repetitive behaviors considerably increases the stability of autism spectrum diagnoses over time and the differentiation between ASD and other disorders.
Reorganization of subdomains increases clarity and continues to provide adequate sensitivity while improving specificity through provision of examples from different age ranges and language levels.
Unusual sensory behaviors are explicitly included within a sudomain of stereotyped motor and verbal behaviors, expanding the specfication of different behaviors that can be coded within this domain, with examples particularly relevant for younger children
Autism spectrum disorder is a neurodevelopmental disorder and must be present from infancy or early childhood, but may not be detected until later because of minimal social demands and support from parents or caregivers in early years.
Severity Level for ASD:
Level 3 ‘Requiring very substantial support’
Social Communication
Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions and minimal response to social overtures from others.
Restricted interests & repetitive behaviors
Preoccupations, fixated rituals and/or repetitive behaviors markedly interfere with functioning in all spheres. Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interest or returns to it quickly.
Level 2 ‘Requiring substantial support’
Social Communication
Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from others.
Restricted interests & repetitive behaviors
RRBs and/or preoccupations or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress or frustration is apparent when RRB’s are interrupted; difficult to redirect from fixated interest.

Level 1 ‘Requiring support’
Social Communication
Without supports in place, deficits in social communication cause noticeable impairments. Has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions.
Restricted interests & repetitive behaviors
Rituals and repetitive behaviors (RRB’s) cause significant interference with functioning in one or more contexts. Resists attempts by others to interrupt RRB’s or to be redirected from fixated interest.
This information was taken from  and


  1. Thank you for this. This follows more what my understanding has been of the new vs. Current guidelines. I appreciate the unbiased info!

  2. Hmm. This new criteria does not seem to specifically exclude intellectual disability, which is being reported. Also, since the new dx criteria does not specifically require a language delay, I bet a lot of Aspies will meet this criteria as well. They may be lumped together with anyone with ASD, but I bet a lot of them will still be considered on the (narrower) spectrum.

    I wonder how this is going to go. My son has received grant money here and there specifically because he had a noticeable spoken language delay along with an ASD dx. But either way, he seems to still meet this criteria. He has always had classic autism, however, so it's really no surprise.

    I guess we will see next year, huh!

  3. Great to see some blogs addressing this issue without hysteria. Thanks.