ASD Editorial

Editorial Autism spectrum disorders (ASDs) have been one of the prevalent neurodevelopmental disorders with individual epidemiological studies ranking as high as 2.64% (Kim, Leventhal, & Koh, 2011). Other than a true increase in incidence, the proliferation of ASD has been implicated with improved clinical awareness, practical usage of labels in educational environments, as well as an expansion of diagnostic criteria accommodating more than autistic disorders (Fombonne, 2005). In the Diagnostics and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Autistic Disorder, Rett’s Disorder, Childhood Disintegrative Disorder (CDD), Asperger’s Disorder (AD), and Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS) are classified under Pervasive Developmental Disorders (PDD) (American Psychiatric Association, 1994). These disorders are characterized by qualitative impairment in three diagnostic constructs: social, communication, and atypical behaviors. Diagnosis of autistic disorder is only made when not better accounted by Rett’s Disorder or CDD. Rett’s disorder is defined as the development of multiple impairments in expressive/receptive language development. CDD is characterized by a clinically significant loss of expressive or receptive language, social skills, adaptive behavior, bowel or bladder control, play, or motor skills. There is also a qualitative impairment in social interaction, communication, and restricted repetitive behaviors (RRB). Both disorders follow a period of regular prenatal and perinatal psychomotor development (CDD: 2 – 10 years; Rett’s: 6-18 months). The main difference between the two disorders is that Rett’s exhibits a dramatic decrease in skull and cortex growth, often leading to profound mental retardation (APA, 1994). Autism spectrum disorder (ASD) is a new term in the Diagnostics and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) replacing PDD reflecting four



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separate neurodevelopmental disorders (autistic disorder, AD, CDD, and PDD-NOS) as a single condition with varying levels of severity in two core diagnostic constructs: (i) Monothetic deficits in social interaction and communication, (ii) RRBs with regards to interests, and activities. It is noteworthy that both constructs are required for the diagnosis of ASD, if not it may be diagnosed as social communication disorder (SCD) if no RRBs are reported (American Psychiatric Association, 2013). When Asperger’s disorder (AD) made its debut in DSM-IV, this pushed forth the identification of children of higher cognitive and language abilities with impairment to social abilities. Some have proposed that the increased visibility of AD diagnosis suggests that individuals who require intervention are being better diagnosed and allowed improved accessibility to services (Ghaziuddin, 2010; Tsatsanis, 2003). The omission of AD in the DSM-5 lies in three significant differential diagnoses from autistic disorder: inability to meet diagnostic criteria in the communication domain and language delay; absence of onset prior to three years; absence of cognitive/non-social development deficits (Ghaziuddin, 2010). Diagnosis for ASD in the DSM-5 also requires that individuals exhibit deficits in social interaction and RRBs (Buitelaar, Van der Gaag, Klin, & Volkmar, 1999). This omission has faced ethical backlash, with many arguing that the DSM creates stigmatizing labels, and its many changes has both granted and taken away from the social identity of individuals who may desire to gain ownership of their own diagnoses (Kutchins & Kirk, 1997; Lane, 2007; Szasz, 2007). It has been argued that the extinction of AD in DSM-5 is in fact an absorption into the novel inclusion of SCD defined by impairments in social communication that are not attributable to language or general cognitive abilities (Giles, 2014). This has been criticized, as symptoms for diagnosis need to be present in early childhood, making retrospective



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diagnosis difficult for those with symptom presentation in adolescence (Wing, Gould, & Gillberg, 2011). McPartland, Reichow, and Volkmar (2012) conducted studies evaluating the specificity and sensitivity of DSM-5 diagnostic criteria and found that revised criteria improve specificity with 94.9% individuals accurately excluded from the spectrum. However, sensitivity varied substantially based on diagnostic group (autistic disorder = 0.75; AD = 0.25; PDD-NOS = 0.28). This shows an exclusion of a substantial portion of those with ASDs other than autistic disorder. ASD is defined by a common set of behaviors that have been argued to be best represented within a single diagnostic category adapted to individual’s clinical severity (McPartland et al., 2012; Tsatsanis, 2003; Wing et al., 2011). Therefore the progressive dimensional approach has been supported as a better representation rather than categorically distinct groups (Bentall, 2009). Others have supported the omission of AD due to the mistaken categorical assumption that AD individuals are intellectually superior, an assumption grounded in the antiquated erroneous belief that autism severity is determined by general cognitive ability (Giles, 2014). The differentiation between AD and high functioning autism (HFA) has also been pointed out to be an extremely problematic undertaking as no clinical, neuropsychological, or behavioral indicator is able to discriminate between individuals with AD and HFA reliably (Campbell, 2005). Given the commonality of diagnostic features, the pursuit for phenotypic differentiation has also been met with much disagreement in previous literature (Klin, Volkmar, Sparrow, Cicchetti, & Rourke, 1995; Manjiviona & Prior, 1999). In accordance to this, many have shown support; pointing out that differentiation of ASD from other neurodevelopmental disorders can be done with high reliability and validity (Ghaziuddin, 2010; Tsatsanis, 2003). However, distinctions amongst PDD and ASD disorders have been inconsistent over time,



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variable across studies, and are often occupied with severity in language or cognitive deficits as opposed to features of the disorder (McPartland et al., 2012). Changes in diagnosis within the realm of psychiatry rarely consider the implications upon the social identity of affected communities, or in this case the selfadvocacy within the autism community (Silverman, 2012). Within these tight knit communities where diagnosis is often deemed as a necessary qualification for social membership, the change in diagnosis is sure to exclude many (Giles & Newbold, 2011). The return of previously diagnosed AD individuals to neurotypical (NT) communities without the Asperger’s label could lead to individuals having to take responsibility for social oddity, excusing it as social malfunction and losing access to entitlements and medical services (Giles, 2014). With regards to future revisions of the DSM, as difficult as it may be, it is crucial to realize that these decisions do not take place within a clinical vacuum. Beyond looking towards scientific rationale, the APA should also attempt to take social ramifications into consideration.



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References American Psychiatric Association. (1994) Diagnostic and statistical manual of mental disorders (4th ed.), Washington, DC: Author American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders (5th ed.), Washington, DC: Author Bentall, R. P. (2009). Doctoring the Mind: Why Psychiatric Treatments Fail. London: Allen Lane. Buitelaar, J. K., Van der Gaag, R., Klin, A., & Volkmar, F. (1999). Exploring the boundaries of pervasive developmental disorder not otherwise specified: analyses of data from the DSM-IV Autistic Field Trial. Journal of Autism and Developmental Disorders, 29, 33-43. Campbell, J. (2005). Diagnostic assessment of Asperger’s disorder: A review of five third-party rating scales. Journal of Autism and Developmental Disorders, 35(1), 25-35. Fombonne, E. (2005). Epidemiological studies of pervasive developmental disorders. In F. R. Volkmar, A. Klin, R. Paul, & D. J. Cohen (Eds.), Handbook of Autism and Pervasive Developmental Disorders (3rd ed., pp. 42-69). New Jersey: Wiley. Ghaziuddin, M. (2010). Should the DSM V drop Asperger syndrome? Journal of Autism and Developmental Disorders, 40, 1146-1148. Giles, D. C. (2014). ‘DSM-V is taking away our identity’: The reaction of the online community to the proposed changes in the diagnosis of Asperger’s disorder. Health:, 18(2), 179-195. Giles, D. C., & Newbold, J. (2011). Self- and other-diagnosis in user-led online mental health communities. Qualitative Health Research, 21(3), 419-428.



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Kim, Y. S., Leventhal, B. L., & Koh, Y. J. (2011). Prevalence of autism spectrum disorders in a total population sample. American Journal of Psychiatry, 168, 904-912. Klin, A., Volkmar, F. R., Sparrow, S. S., Cicchetti, D. V., & Rourke, B. P. (1995). Validity and neuropsychological characterization of Asperger syndrome: Convergence with nonverbal learning disabilities syndrome. Journal of Child Psychology and Psychiatry and Allied Disciplines, 36, 1127-1140. Kutchins, H., & Kirk, S. A. (1997). Making Us Crazy: DSM – The Psychiatric Bible and the Creation of Mental Disorders. New York: The Free Press. Lane, C. (2007). Shyness: How Normal Behavior Became a Sickness. New Haven, Connecticut: Yale University Press. Manjiviona, J., & Prior, M. (1999). Neuropsychological profiles of children with Asperger's syndrome and autism. Autism, 3, 327-356. McPartland, J., Reichow, B., & Volkmar, F. (2012). Sensitivity and Specificity of Proposed DSM-5 Diagnostic Criteria for Autism Spectrum Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51(4), 368-383. Silverman, C. (2012). Understanding Autism Parents, Doctors, and the History of a Disorder. New Jersey: Princeton University Press. Szasz, T. S. (2007). Coercion as Cure: A Critical History of Psychiatry. New Jersey: Transaction Publishers. Tsatsanis, K. D. (2003). Outcome research in Asperger syndrome and autism. Child & Adolescent Psychiatric Clinics of North America, 12, 46-63. Wing, L., Gould, J., & Gillberg, C. (2011). Autism spectrum disorders in the DSM-V: Better or worse than the DSM-IV? Research in Developmental Disabilities, 32, 768-773.



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