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A Change in Diagnosis
Autism Spectrum Disorder:
A Change in Diagnosis
Rachel Painter
University of Cincinnati – Blue Ash
Autism Spectrum Disorder (ASD) is a lifelong neurological disorder which, according to
the Center for Disease Control and Prevention, currently affects about one in every 88 children
A Change in Diagnosis
in the United States. These numbers are astounding not only because they have been
consistently rising in recent years, but as of now, despite many studies and research, the
etiology is not certain (Couteur & Yates, 2012). ASD is a heterogeneous condition with no single
pathognomonic feature or specific diagnostic test (Couteur & Yates, 2012). According to
Couteur and Yates, diagnosis can be challenging as affected individuals can not only display
variation in the degree of behavioral severity, language and intellectual abilities across the
diagnostic domains, but their behavioral profiles can change with age. It is implied then that
potential lack of recognition of appropriate behaviors at an early age and a difficult diagnosis
leads to children who most likely have been displaying symptoms at 15-18 months, do not
receive a diagnosis until they are 4-5 years old (Couteur & Yates, 2012). Because of the
challenges faced by medical professionals when diagnosing autism, it is vital that a level of
awareness reaches the general public as well as educators in order to ensure proper diagnosis
and provide the best possible support for these individuals.
It is possible that there is an inadequate amount of education available for educators
and therapists and rising cases of ASD, allowing children are misdiagnosed regularly and are not
given proper treatment or support for their disorder. Subsequently, specifically with the cause
being unclear and education minimal, awareness of autism spectrum disorder has not caught
up to the amount of cases in ASD.
Environmental factors, such as unseen toxins in the air we breathe, mercury poisoning,
milk, vaccinations, and even the higher sales of organic foods can be linked to the cause and
prevalence of ASD. Many of these claims lack sufficient support to be seen as a sole cause or
have been tested and negated. According to Kozlowski, Matson, and Worley, the most
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consistently supported link to ASD is the interaction of multiple genes. Considering that only
about 10% of ASD cases are nomothetic, it is clear as to why determination of etiology is so
difficult to pinpoint.
Previous diagnosis of autistic disorder included a child having a total of 6 or more
symptoms within three categories before the age of three. These first category was social in
which the individual had to have at least two of the symptoms including a deficit in eye contact,
showing and sharing, and emotional reciprocity. The second category was communication
which included the child having a deficit in language, pretend play and/or conversation. The last
category was stereotypic and repetitive behaviors including routines, preoccupation, intense
focus, and motor skills. Children with Asperger syndrome had to display at least two social
deficits and at least one stereotypic/repetitive behavior, with no requirement to meet any
communication deficit. Pervasive developmental disorder not otherwise specified, or PDDNOS,
had the same requirements of Autism Disorder but required less than 6 symptoms.
(Granpeesheh, 2013)
The most noticeable difference in the DSM-V is the new autism spectrum disorder
(ASD), which is a merging of autistic disorder, Asperger's disorder, childhood disintegrative
disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS)
(Granpeesheh, 2013). The new diagnosis of ASD is broken down into four criterion that an
individual must be showing symptoms in each beginning in early childhood. Criterion A has
joined communication and social deficits together into one criteria in which a child must show
signs of deficits in social-emotional reciprocity, non-verbal communication, and developing and
maintaining relationships. Within each sub-category is a wide range of deficits a child may have,
A Change in Diagnosis
allowing the diagnosis to remain unique to the individual instead of forcing the diagnosis to be
too narrow. This merging of social and communication makes sense as it is nearly impossible to
have a communication delay without a speech delay. If a child has no way to communicate or is
non-verbal, socialization would be minimal if at all present. However, Volkmar and Reichow
(2013) notes that by requiring all three social criteria there could be a delayed diagnosis (and
consequentially the delay of intervening) for children whose symptoms do not fully manifest
until social demands increase.
Criterion B includes restricted, repetitive patterns of behavior, interests or activities and
at least two symptoms must be present in the individual. The most notable change within this
category is the addition of sensory related issues which was not present in the DSM-IV. Sensory
issues include unusual or intense interest in sensory aspects of the environment including
adverse response to specific sounds or textures, fascination with lights or spinning objects, etc.
(Granpeesheh, 2013) This is a welcome addition to diagnosis as it was extremely common for
children previously diagnosed with autistic disorder to have sensory related issues that required
treatment but was not part of the technical diagnosis.
Criterion C states that symptoms must be present in early childhood (but may not fully
manifest until social demands exceed limited capacities). The first part of this criteria has not
changed from the previous diagnosis but the addition is a clarification that could pertain
specifically to new parents who may not otherwise know what is or is not normal behavior in
their child and the first person recognizing symptoms is, for example, a teacher when the child
is four years old. This allows for diagnosis even if symptoms were not recognized in the first
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three years of the child's life. The last criterion, Criterion D states that symptoms must limit or
impair everyday functioning.
These changes are important for many reasons, both positive and negative. Due to a
more specific diagnosis, it is possible that individuals previously diagnosed with classical autism,
or autistic disorder, could be better served pathologically and educationally. The levels of
severity now presented in the DSM-V, levels one through three, state that the child requires
some sort of support from general to very substantial, providing a more clear guidelines on
beneficial supports. Children are now able to be diagnosed with ASD and various other
syndromes such as intellectual disability or Rett Syndrome which was previously not allowed. In
the former diagnosis criteria, children with autism disorder who were found also to have a
genetic disorder, such as Rett Syndrome, would no longer be labeled autistic, causing all
funding and support to be removed (Granpeeseh, 2013). This addition is highly important
considering that 70% of individuals meet the diagnostic criteria for at least one other disorder.
(Couteur & Yates, 2012, p.7)
For those currently diagnosed with Autistic Disorder it is a concern that as diagnostic criteria
changes, they may potentially lose diagnosis and services. However, according to Jerome
Wakefield (2013), that is not the case and those currently receiving special education services
and treatments will continue to receive them as they will be "grandfathered in" to the new
diagnosis criteria, even if they do not satisfy the current criteria. While this is great news for
those currently receiving services, a recent comparison done by Dr. Fred Volkmar showed a
bleak outlook for those who may potentially be diagnosed. By comparing results from a 1993
study of 372 participants among the highest functioning and determined that about a quarter
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of those diagnosed with “classical autism,” three quarters of those previously diagnosed as
Asperger’s Syndrome, and 85% of those previously diagnosed with PDD-NOS, would not qualify
for diagnosis under the new criteria (Carey, 2012). Based on various factors involved in the
comparison it is possible that these numbers may be exaggerated but its implication is very
clear in that many high functioning individuals would potentially not qualify for current, more
narrow, diagnosis of autism spectrum disorder.
While these changes may prove to provide more specificities in terms of diagnosis of individuals
with autistic disorder, there are many concerns involving those on the high to very high end of
the autism spectrums. This would include those diagnosed with Asperger’s Syndrome and PDDNOS. These disorders and syndrome are no longer part of the DSM-V, requiring all future
individuals diagnosed to fall into the guidelines of the autism spectrum disorder which could
potentially prove too narrow for these patients. Asperger's Syndrome is a neuro-biological
disorder on the higher functioning end of the autism spectrum with symptoms ranging from
mild to severe (ASPEN, 2013). Typically, individuals with Asperger's have a normal to very
superior IQ but have difficulties with social and communication skills. Characteristics are unique
to each individual but include; literal interpretation of meanings, difficulty with "give and take"
relationships, extreme difficulty in developing age-appropriate peer relationships, and inflexible
adherence to routines (ASPEN, 2013). While these characteristics make up the
social/communication aspect of the autism spectrum diagnosis, these individuals do not always
display symptoms such as stereotypic behaviors or may not be present until the child reaches
school age. Lori Shery, president of the Asperger Syndrome Education network writes, “Our fear
is that we are going to take a big step backward, if clinicians say, ‘These kids don’t fit the criteria
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for an autism spectrum diagnosis,’ they are not going to get the supports and services they
need, and they’re going to experience failure.”
Social (Pragmatic) Communication Disorder is among the changes of the DSM-5 which
recognizes individuals who have significant problems using verbal and nonverbal
communication for social purposes, leading to impairments in their ability to effectively
communicate, participate socially, maintain social relationships, or otherwise perform
academically or occupationally (DSM-5, 2013). While there was no previous diagnosis that
focused primarily on social and communication delays or deficits, the concern is, because it is
not within the autism spectrum, very high functioning individuals who may have previously
been diagnosed with Asperger's Syndrome or high functioning Autistic Disorder, will fall into
this category. According to Dr. Fred Volkmar of Yale University, it seems that this new diagnosis
and its implications are unclear as to what types of services may be available to patients
diagnosed with Social Communication Disorder. His primary concern is the loss of psychiatric
services and accommodations within the education system which may greatly benefit the
individual.
Considering the social, speech, behavior, and sensory issues an individual with ASD may have, a
variety of therapies are available to enable the building of skills. As many individuals diagnosed
the ASD are prone to anxiety and depression, various psychiatric therapies are beneficial for
optimal mental health. An individual educational aide, time spent out of the classroom in a
center focusing on sensory and motor skills, and permission to switch classes early in order to
prevent sensory overload are examples of accommodations that are granted to diagnosed
individuals.
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Applied Behavior Analysis (ABA) is a widely used therapy for individuals diagnosed with autism,
using reward and positive reinforcement along with techniques designed to increase useful
behaviors and reduce those that may cause harm or interfere with learning (Autism Speaks).
The organization Autism Speaks writes that the use of these techniques could build basic and
complex social and communication skills that help individuals with autism live successful and
fulfilling lives.
Speech-language therapy is a progressive treatment building receptive and expressive language
skills, articulation, pronunciation, and fluency, among other communication and language
disorders. Using techniques that could involve visual connections, imitation, and sentence
structure, this therapy is essential to some and beneficial to all as criterion of ASD includes
possible language and speech delays.
Occupational therapy focuses on enhancing children's sensory processing, sensory-motor
performance, social-behavioral performance, self-care, and participating in play. As the child
gets older, the goals may change to focus on independence in the community and transition
into the workforce (Arbesman & Smith, 2008).
Social skills groups, implementation of art and music, the Reading with Dogs program, and the
assistance of animals are various other therapies and techniques that could be used on a
regular or as-needed basis. The amount and intensity of each program is dependent and unique
to each individual. It is important for therapists to be well versed in all levels of the autism
spectrum in order to determine the most efficient plan for the child. Unfortunately, continuing
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education opportunities that are specific to autism spectrum disorder are not as prevalent as
growing statistics show they should be (Grandpeesah, 2013). .
It is vital as time moves forward that the general public, medical practictioners, and educators
are properly educated with the many facets of autism spectrum disorder.
References
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