DSM stands for “Diagnostic and Statistical Manual of Mental Disorders,” which is a manual published by the American Psychiatric Association. The manual includes classifications of psychiatric disorders for use by medical and mental health professionals. Clinicians may refer to versions of the DSM to look for diagnostic codes of different disorders and examine criteria for diagnosis. About 25% of the disorders are specific to children and are in the section of “Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence.” Autism and related disorders have been specifically included in different versions of the DSM since 1980.
The American Psychiatric Association has recommended making changes related to Autism Spectrum Disorders (ASD) in a new edition of DSM, DSM-5, which is scheduled for publication in 2013. There has been much discussion in the media and in clinical and research organizations about the changes. At this point, the proposed changes are still under review and are not considered final.
DSM-5 consolidates autistic disorder, Asperger’s Disorder, and Pervasive Development Disorder-Not Otherwise Specified (PDD-NOS) under one overarching category of Autism Spectrum Disorders (ASD).
The category of “Pervasive Development Disorder” will no longer be used in DSM-5. The reason for consolidating separate diagnoses into one is that research has shown that the DSM-IV definitions of Autistic Disorder, Asperger’s Disorder, and PDD-NOS do not identify real differences in the biology, response to treatment, or other outcomes of the individuals with these diagnoses. Under DSM-5, an individual with ASD must have (1) “persistent deficits in social communication and social interactions” and (2) “restricted, repetitive patterns of behavior, interests or activities.” This is another change from DSM-IV, which separated out social and communication symptoms into independent symptom domains. This change makes sense because social abilities and communication are interrelated and inseparable in the real world. In DSM-5, there are 3 symptoms listed under social communication deficits and individuals with ASD must have all 3. Individuals with ASD must have 2 of 4 of the symptoms of restricted, repetitive behaviors listed. There are new descriptions of these symptoms, which were not present in or which have been revised from DSM-IV.
DSM-5 adds a new “severity scale” designed to be more descriptive of the impact of ASD on everyday functioning.
There are 3 levels of severity proposed. Level 3 severity corresponds with the need for “very substantial support,” Level 2 is for individuals who require “substantial support,” and Level 1 is for those “requiring support.” Needs for support are defined separately for social communication deficits and restricted interests and repetitive behaviors. This means that, for example, an individual may be a Level 3 in the realm of social communication, but have less severe symptoms of repetitive behaviors which need only a moderate level of support. As of now, there are no specific guidelines on how to assign a severity level.
Despite much discussion in the media, there is not enough evidence to know if the new criteria proposed in DSM-5 will restrict the ability to obtain an autism spectrum diagnosis.
Many families are worried that some people who previously may have qualified for a diagnosis in DSM-IV will be excluded from a diagnosis of ASD by DSM-5. Some researchers have examined retrospective data (records from when individuals were diagnosed in the past) and have expressed concerns that people who do not have intellectual disability might be excluded. Other studies using different sets of retrospective data have shown that the number of ASD diagnoses may increase. DSM-5 criteria are worded differently than past versions of the DSM and contain new symptoms never before included. (For example, sensory sensitivities are now taken into account.) No one can be sure of the effect of DSM-5 on the number of ASD diagnoses until new studies occur which perform evaluations of individuals using both the old and new diagnostic criteria. These prospective studies should also examine any effects of the new criteria on access to services. An autism diagnosis is just one piece of information that goes into determining whether a person is eligible for services, and eligibility determinations also must consider how the person is functioning. There may, however, be some benefits particular to having an autism diagnosis, such as preferred timelines, smaller class sizes, or insurance benefits, which may or may not be available if an individual loses the autism label.
If an individual does not meet criteria for ASD using DSM-5, there are other diagnostic categories that may apply.
Some individuals who do not qualify for an ASD diagnosis under DSM-5 may be included in a new category called “Social Communication Disorder” (SCD). SCD is a subcategory under “Communications Disorders” in DSM-5. SCD is defined as “an impairment of pragmatics.” Individuals with SCD have difficulty in the social uses of verbal and nonverbal communication in naturalistic contexts, which impacts their development of social relationships and comprehension of social conversation. Difficulties cannot be explained by factors such as general cognitive ability. Autism Spectrum Disorder must be ruled out before a diagnosis of SCD can be made. Some individuals who no longer meet criteria for ASD under DSM-5 may meet criteria for other DSM-5 diagnoses, including “Intellectual Developmental Disorders,” other “Communication Disorders,” “Anxiety Disorders,” and/or “Attention Deficit/Hyperactivity Disorder.”
DSM-5 may pave the way to more adult ASD diagnoses, but it is unclear how it may impact diagnoses in young children.
Rather than requiring that symptoms be present in early childhood, DSM-5 opens the door to adult diagnoses by acknowledging that symptoms may not always become apparent until social demands increase, for example in adolescence or adulthood. Additionally, the added severity scale may help to substantiate the need for supportive employment and accommodations in the workplace. Experts are still skeptical about whether DSM-5 will improve the early identification of symptoms in young children. Very early identification was difficult with DSM-IV criteria because many of the observable symptoms of ASD are simply not appropriate to even consider in young children. DSM-5 does a better job of describing how behaviors might be manifested in people across a wider age range, but it’s not clear yet whether the new criteria will be able to capture all of the very young children with autism. Early detection and diagnosis of autism is a developing field, and researchers hope that new scientific findings will one day soon inform clinical diagnostic practice.