Relaxed requirements
Three studies published between last summer and this month conclude that the DSM-5 criteria for ASD are too strict, but that a few small changes would make them appropriately inclusive. One might think that the APA would conduct such research themselves, but studies that explicitly compare DSM-IV and DSM-5 criteria are not an official part of the revision process. Rather, researchers who are not helping revamp the DSM, but were interested in how the new edition will change psychiatric diagnosis, decided to find out for themselves.
Marja-Leena Mattila of the University of Oulu in Finland conducted the only epidemiological study published so far that explicitly compared the two editions' criteria for autism. (Mattila used DSM-5 criteria posted to the DSM-5 Development Web site in February 2010; the criteria have the same basic structure as the new specifications posted in January 2011, but they are far less detailed and descriptive.) In her study, Mattila surveyed a sample of more than 5,000 Finnish schoolchildren and identified 26 eight-year-olds with an IQ of 50 or higher who qualified for autistic disorder in the DSM-IV. Of those 26, only 12 qualified for ASD in the DSM-5. But when Mattila lowered the threshold for ASD by requiring only two of the three symptoms in the social interaction and communication group, 25 of the 26 children qualified for ASD in the both the DSM-5 and its predecessor. Her work appears in the June 2011 issue of the Journal of the American Academy of Child and Adolescent Psychiatry.
Similarly, Thomas Frazier of the Center for Autism at the Cleveland Clinic performed a series of statistical analyses on symptom reports from nearly 7,000 ASD children, looking for the symptoms that appeared together most frequently. When he programmed a computer to figure out what kind of diagnostic model best reflected the naturally occurring clusters of symptoms, Frazier found that a model with two groups of symptoms—just like the one in the DSM-5—captured how the symptoms clustered in the children better than the DSM-IV or any other model. He also found that the DSM-5 model misdiagnosed autism in only 3 percent of the children, whereas the DSM-IV model misdiagnosed autism in 14 percent. When Frazier relaxed the DSM-5 requirements from five out of seven criteria to four out of seven, he brought back about 12 percent of ASD children that the model originally neglected.
William Mandy of University College London also used statistical analyses to evaluate the DSM-5 criteria and concluded that the two-group DSM-5 model is overall more accurate than the three-group DSM-IV model, but a little too restrictive. Both Frazier's study and Mandy's study are published this month in the Journal of the American Academy of Child and Adolescent Psychiatry.
"They got the major changes right," Mandy says of the APA. "But recent evidence shows that borderline people might miss out on a diagnosis in DSM-5 because they don't have clinical levels of some symptoms, such as repetitive behavior. The real issue is threshold." Not all psychiatrists agree that the stricter DSM-5 criteria should be relaxed, because they think that many people currently diagnosed with Asperger's or PDD-NOS do not in fact have autism and that the new definition of ASD should not include these people. Some parents of children with severe autism are also in favor of stricter criteria, arguing that children who are most in need should receive state services over others with milder symptoms.
Darrel Regier, vice chair of the DSM-5 Task Force, says that he is well aware of the recent studies and that the committee will consider whether they need to revise the DSM-5 criteria for ASD even further. The APA is supposed to finalize all changes to the DSM this year and publish the new edition in May 2013. When asked if he thinks the APA can adjust the revisions to criteria not only for ASD, but for all the other disorders in the DSM-5 by the end of this year, Regier says "there is plenty of time."
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7 Comments
Add CommentThe problem is not in denying people a "diagnosis" but that a subculture of pseudo-professionals dabbling in the pseudo-science of "therapy"have taken it upon themselves to define every single human thought or behavior as something that is sadly abberrant and therefore desperately in need of their tender ministrations.... that just happens... to result in compensation for them.
Reply | Report Abuse | Link to thisThe problem with the therapy industry is that it engages in pseudo-science right up there with creationism when it comes to bafflewit circular thinking.
The DSM-s are just collections of insurance reimbursement categories.... and do not map well onto the real world at all.
They are the same sort of effort as Astrological readings in the newspaper... things written in such a way that it is easy to interpret the words to truthfully apply to some vast number of readers.
The study of psychology of the human is a worthy and sometimes scientific endeavor. The world of the therapist... is a world of the unenlightened self-deluded pseudo-scientist... the out and out con-artist..... and the sociopath.
The contrast is the same as we see in astronomy vs astrology.
Astronomy is the science of describing and understanding the stars... astrology is a pseudoscience that starts in the same basic place as astronomy and then veers off the path of rationality.
So too, is the study of the human mind... some small amount of science can be done in that study.... we call that the study of psychology.... then you get the therapy industry.. who start in the same place and then veer off the path and into the thicket and swamp that is irrationality.
Anne Dachel wrote: "The Baltimore Sun published this story this past July, 'We don't know enough about childhood vaccines--Researcher asks: Are 36 doses of vaccine by age 2 too much, too little, or just right?'"
Reply | Report Abuse | Link to thisThe "news story" was actually an opinion piece by an anti-vaccine "researcher".
Meanwhile, bona fide researchers have come to an opposite conclusion.
Whatever the definition used for autism, or autism spectral disorders, it should be based on medical/causal/treatment criteria.
Reply | Report Abuse | Link to thisThe autism community has been very successful is placing something called autism in the forefront, replacing ADD, ADHD, etc. as the mental disease du jour. And money has flowed into this problem. My sense is when lots of money for autism treatment and research is available, diagnosis of autism increases. Of course it must.
Every practitioner wants to be paid, every kid who actually has an issue should be treated. If the choice is to label something autism and get treatment, or give it some other label, and the child not be treated and the practitioner not be paid, and you have a clear reason to label everything you can as autism. Likewise, if funds are tight, and money needs to be saved, then defining autism more narrowly will improve the bottom-line.
It is a perversion of the pursuit of competent scientific study to allow access to money to determine diagnosis. These disorders, such as they are, must be diagnosed/labeled in such as way as to support the understanding of the disorders as well as determining the appropriate treatment. Science, not anything else, must be used to discriminate between patterns of mental activities.
It is beside the point whether the new or old classifications exclude or include some people. The question must be are the classifications scientifically justified.
The over-diagnosis of autism in our school districts has sucked all of the money out of the gifted programs because by federal law you are essentially handcuffed from making any cuts for any economic reason at all. It even affects other programs that I believe are beneficial to autistic students and art is of special concern since autistic people have a tendency to see everything in "pictures". Temple Grandin video on TED comes to mind immediately.
Reply | Report Abuse | Link to this@amdachel Spamming this board about all you have accomplished. By any objective measure, the level of real Autism is way over-diagnosed.
Please take a moment and consider signing and sharing this petition to preserve the availability of services for many individuals on the spectrum. It only takes a moment to sign and costs nothing to take a stand against this proposal that could hurt many: https://www.change.org/petitions/do-not-remove-aspergers-syndrome-and-other-autism-sub-types-from-dsm
Reply | Report Abuse | Link to thisbrain dead doctor syndrome
Reply | Report Abuse | Link to thisI am reading Kahnemann's "Thinking: Fast and Slow" and I finally 'get' anti-vaxers and other science deniers. The intrinsic appeal of a causal narrative (usually only slightly useful but mostly completely wrong)is as appealing as a crack pipe. Deniers run constantly in System 1 (fast) cognition mode where their mental efforts end just before introspection intervenes. The irrational marriage of ego and a 'just so story' defeats any effort to engage that brain's owner in System 2 (slow, rational) thinking. Anti-vaxers live on in the comments as System 1, copypasta-fast-draw artistes. Bringing up an 'false equivalence' article in the Baltimore Sun Sunday Style section in a comment in SA is choice.
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