Diagnostic Changes

Triad of Impairment

This is the term that has described the difficulties that people with autism experience in differing degrees. Up until now diagnosis has been based on the difficulties listed in the Triad. While diagnostic criteria may have changed ( see DSM-5 below),  I feel that the Triad still has relevance, so I am including it in this section.

Social Interaction – getting on with other people

Symptoms in this area include:

  • Ritualistic, compulsive and obsessional type behaviours.
  • Self-stimulating and repetitive behaviours.
  • Compulsive ritualistic use of language.
  • Lack of concept of self and others as beings with feelings and individual thoughts.

Difficulties range from indifference and aloofness to wanting desperately to make friends but not understanding social rules and other people’s behaviour and feelings well enough to do so successfully. Some people with autism find social situations very challenging and may avoid interaction altogether. A child with autism may not be able to respond to his or her own name and can avoid looking at other people. Interpreting tone of voice or facial expressions could be problematic for an autistic person as can responding to others’ emotions appropriately. Autism causes children and adults to appear oblivious to the negative impact that their behavior has on others.

Verbal and Nonverbal Communication – talking & understanding

Many individuals with Autism have poor auditory processing. This means they take time to make sense of what is being said. This can mean they have problems in some of the following areas:

  • Talking and understanding
  • Speech may be present but not used for spontaneous communication
  • Maybe seen as un-cooperative or unresponsive
  • Tantrums or severe episodes of distress can result due to not being able to express themselves
  • Development of language can be concrete and literal
  • Inability to read facial expression, gesture, body language and posture.
  • Impairment of the understanding meaning – semantic and pragmatic.

Language difficulties range from no speech at all to fluent speech that can be repetitive and focused on their own areas of interest, rather than true conversation.

Limited Imagination and Rigid Thought Processes – thinking & behaviour

“We have trouble working out what other people know. We have more difficulty guessing what other people are thinking.”

Social imagination allows us to understand and predict other people’s behaviour, make sense of abstract ideas, and to imagine situations outside our immediate daily routine.

Symptoms can include:

  • Skills are learnt in isolation and not generalised into other areas.
  • Preoccupation with sameness
  • Difficulty with change
  • Inability to learn successfully by mistake, trial or error
  • Poor play skills and difficulty in developing imaginative play
  • Difficulties in manipulating objects appropriately
  • Seeming impairment of curiosity of the direct world
  • Repetitive activities
  • Inability to differentiate between fantasy and reality

The deficits in imaginative and conceptual skills and difficulties in making sense of the world can lead to a rigid way of thinking and doing things, repetitive activity and narrow interests. Changes of routine can cause anxiety and distress.

 

 Changes to Diagnosis

The American Psychiatric Association (APA) has revised its diagnostic manual, known as Diagnostic and Statistical Manual (DSM). This is one of the two main  sets of diagnostic criteria, used internationally, for autism spectrum disorders, including Asperger syndrome.

Diagnostic criteria are revised periodically by a team of experts, taking into account the most up-to-date research. For the this edition of the DSM, DSM-5,  changes have been made which affect the way diagnoses will be given to people on the autism spectrum.

Here are some of the main changes:

  • The terms used in the DSM-4 were autistic disorder, Asperger’s disorder, childhood disintegrative disorder and PDD-NOS (pervasive developmental disorder not otherwise specified). changes in DSM-5 mean that when people go for a diagnosis now, instead of receiving a diagnosis of one of these disorders, they would be given a diagnosis of ‘autism spectrum ‘. While the term Asperger may eventually disappear under the term ‘high functioning autism’, I  feel that the criteria for Asperger syndrome are relevant. (See Asperger Syndrome)
  • The ‘Triad of Impairments’ is reduced to two main areas:
    1. social communication and interaction.
    2. Restricted, repetitive patterns of behaviour, interests, or activities.
  • Sensory behaviours will be included in the criteria for the first time, under restricted, repetitive patterns of behaviours descriptors.
  • The emphasis during diagnosis will change from giving a name to the condition to identifying all the needs someone has and how these affect their life.
  • They are also planning to introduce ‘dimensional elements’ which should give an indication of how much someone’s condition affects them. This should help to identify how much support an individual needs.
  • The new Manual, DSM-5, was published in 2013.

The  Criteria for Diagnosis for Autism Spectrum Disorder from DSM-5 are as follows:

To get a diagnosis of autism the individual must meet criteria A, B, C, and D:

  • 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:
  • 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,
  • 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.
  • 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
  • Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:
  • Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).
  • 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).
  • 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).
  • 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).
  • Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)
  • Symptoms together limit and impair everyday functioning.