Autism & Diagnosis
The DSM (Diagnostic and Statistical Manual) is used by mental health professionals as a means of diagnosing patients and by service providers and insurance companies to determine what disorders and treatments to cover.
What is Autism?
Autism is defined as a developmental disorder that affects the child’s ability to engage in interpersonal and social communication.
“You don’t know where you are going, unless you know where you came from…”
The first edition of the DSM was published in 1952. It contained different illnesses, especially schizophrenia, most of the illnesses were associated with soldiers who had undergone traumas in the 2nd World War. In the second edition of the DSM that was published in 1968, emphasis was given to neuroses. The symptoms themselves were highlighted and less stress was given to the diagnosis. The first and second editions were milestones in psychiatry. The biological aspect was not evident at all. To a certain extent, the decisions that were then made still have an influence on the present. Even today, the DSM-5 does not link up with biology, and this is despite the copious research conducted in this field during the last decade.
The third edition, published in 1980, mainly took a stand against psychoanalysis and was based on short categories of symptoms. But for the first time, the book of definitions was supported by the NIMH, and so it also had broad implications. The DSM-IV that was published in 1994 had mostly minor impact changes, although it brought in, for example, the PDD’s definition and aroused much controversy – yet in the end, we have had 20 years of the “blossoming of definitions”, which have often been used erroneously, so that there has been a sharp rise in those diagnosed with mental disturbances, especially noticeable for the diagnosis of autism.
The fifth edition is perversely influenced by the third. It is conservative and obviously influenced by professional and sociological considerations, but especially by economic and political aspects. The number was altered at the very last moment from its Roman number V to 5 in order to adapt the style for the younger generation. Who could have imagined in 2000, when they began to work on the fifth edition, how digital the world would become in 2013… In the new edition there are 157 defined disorders and classification is needed mainly to distinguish between them.
Autism is a developmental disorder
The definitions for autism have undergone the most extensive alterations. This is also the most researched field. The definitions in the DSM-IV were based on three categories: a) social impairment, b) language impairment, and c) repetitive ceremonial behavior. In the new edition language has been removed and given a separate classification. This was done out of the understanding that what is important is how the child speaks now and not when they began to speak. They kept two criteria: a) social relationships, b) repetitive ritual behavior. The criteria were related to the extent of duration, severity and family suffering.
Autism Spectrum Disorder 299.00
A. Persistent deficit in social communication and social interaction across multiple contexts as manifested:
- Deficit in social-emotional reciprocity
- Deficit in nonverbal communicative behaviors
- Deficit in developing, maintaining, and understanding relationships
B. Restricted, repetitive patterns of behavior, interests or activities, as manifested by at least two of the following:
- Stereotyped or repetitive motor movements, use of objects or speech
- Insistence of sameness, inflexible adherence to routines, or ritualized patterns
- Highly restricted fixated interests that are abnormal in intensity or focus
- Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of the environment, it is noted that the symptoms must appear in early development, but they may not be expressed fully until the stage where there are more complex social demands.
Additionally, children who have difficulties in developing social relationships, who do not show any of the other signs mentioned above, will be diagnosed according to new categories added to the new edition: Pragmatic Social Communication Disorder (PSCD), which unfortunately is likely to replace the PDD… PDD was used similarly for twenty years, many parents felt better with the definition of PDD rather than autism.
Many children may fluctuate between different diagnoses. How wide should the diagnosis be? Is it possible for the child to have no impairment and yet have autism? In a good diagnosis, other things are usually found on the way, that are not necessarily linked to autism. Autism is more than the sum of its parts (Lord, 2013). Today, we understand that there is actually no single disease, and it is clear that there is no gene for autism but rather a group of genes connected with autism. But we still do not know all of them and do not yet understand the link between physiology and environment. We still lack biological markers. That is why most of the treatments are limited. Nevertheless, 80% of the children with autism in the USA are treated with medications from school age. Of course these medications are not intended for autism per-se. 17% of all children in population experience tantrums, 80% of them develop ADHD. There has been a sharp increase in the diagnosis of bipolar disorder in children. Some of them are also diagnosed, perhaps erroneously, with autism. Autism is almost certainly linked to neurobiology, but its expression is behavioral. Most of the data concerning autism are based on parental reports. Yet, diagnosis should be given as a result of observation of the child and family in all life domains and not just at a particular time and location. Introducing Asperger’s Disease into the fourth edition caused a worldwide statistical increase in cases on the autism spectrum. And here we have an example of political considerations: Asperger’s was deleted as a separate category in the last edition because … in the USA services are not given for Asperger’s, only for autism, and since the central problem in Asperger’s is still impairment of social skills, they decided to include it in the autism spectrum and thus meanwhile solved the problem … Even more serious, despite the plentiful studies proving the importance of early identification and treatment, most of the new criteria relate to more mature ages, when social relationships are supposed to be created. The single item that would support early diagnosis is the exclusion of the language component, consequently permitting observation also of babies who are in the pre-language acquisition stage. Thus, diagnosis is possible at the age of one. And the question still remains: Has a developmental regression occurred in the autistic development process or a loss of skills? There is no answer to this. The question of how the clinician should proceed from diagnosis to treatment still remains open. From an operational viewpoint there are essentially 3 possible situations:
- We know what to do
- We have no idea what to do
- We know what to do but we still need a pathway for treatment
One should remember – DSM is not a diagnostic tool but rather a tool providing criteria for diagnosis!
Common Tools for Diagnosis of Autism for Children Over 2 Years Old:
- ADOS – Autism Diagnostic Observation Scale
- ADI-R– Autism Diagnostic Interview – Revised
It is critically important that the diagnostic process takes place at a number of meetings, over several days, so that the child is observed in different situations, at different hours of the day, in order to eliminate the influences of shyness, anxiety, fatigue, hunger, tension, boredom, etc.
Diagnosis of Autism Tools for Toddlers from 18 months to 24 months old:
- ADOS-3-T – (for toddlers)
- M-CHAT – Modified Checklist for Autism in Toddlers
Screening Tool for Infants at Risk for Autism Under 18 Months Old:
- ESPASI – Early Signs of Pre-Autism Scale for Infants, a screening tool developed by the Mifne Center in 2007 as a result of long-term studies on autism in infants.
Assessment and Treatment of Infants is the Expertise of The Mifne Center.