Tuesday, April 2, 2013

Autism Redefined in New Manual of Mental Disorders

By Cristina Mestre


The American Psychiatric Association (APA) publishes the Diagnostic and Statistical Manual of Mental Disorders (known as DSM), which is the standard classification of mental disorders used by health professionals in the United States.

Changes to the fifth edition of the manual, known as DSM-5, were revealed in January, and the manual itself will be published in May.

Among the most controversial of the changes to the DSM-5 are those regarding the definition of autism, which currently falls under the diagnostic category of Pervasive Developmental Disorders, or PDD. In the new manual, autism will be referred to as Autism Spectrum Disorder (ASD). In honor of World Autism Awareness Day today, we asked Martin Lubetsky, M.D., clinical service chief for Child and Adolescent Psychiatry and the Center for Autism and Developmental Disorders at Western Psychiatric Institute and Clinic of UPMC, to explain the significance of the DSM-5’s new classification for autism. 

Q: Can you give us a quick overview of autism? 

A:  Autism is a developmental neurobiological disorder, characterized by severe and pervasive impairments in social interaction and communication skills (verbal and nonverbal), and by restricted, repetitive patterns of behavior, interests or activities.

Q: What are the autism-related changes in the new edition of the DSM?
A: Under DSM-5, the separate diagnostic subcategories under PDD in DSM-IV will now be subsumed under one category - Autism Spectrum Disorder. This puts autistic disorder, Asperger’s disorder, pervasive developmental disorder not otherwise specified (PDD-NOS) and childhood disintegrative disorder ALL under ASD.

The new ASD diagnostic category will include specifiers for severity and verbal abilities, and will also include associated features such as known genetic disorders, epilepsy and intellectual disability. Severity levels are based on the amount of support needed by an individual with ASD; e.g., an ASD patient could be considered “level 1,” “level 2” or “level 3.”

The new ASD diagnostic category will also combine the current three domains of autism symptoms (social impairment, communication impairment, and repetitive/restricted behaviors) into two domains (social interaction and communication deficits, and restricted interests/repetitive behaviors).

Q: I’ve read that a lot of people are concerned with these changes, can you explain why? 
A: Many parents and professionals are questioning the new DSM-5 revised diagnosis of autism. One concern raised is whether individuals currently diagnosed with Asperger’s disorder and PDD-NOS may not meet the new criteria.  The DSM-5 committee has stated that individuals who currently have a diagnosis on the autism spectrum will retain their ASD diagnosis.  A second concern raised is whether  there would be risk of change in school placement or funding for treatment, if a child with autism does not meet the new criteria.  A third concern is whether there would be a loss of “identity” for individuals diagnosed with Asperger’s disorder who will fit into the broader ASD category.

Q: What is the APA’s rationale for these changes?
A: The DSM-5 committee has defended the new categorization as an improvement in accuracy and reliability of diagnosis of ASD.  The APA notes that the new version is more precise, and that autism is defined by a common set of behaviors, therefore should be classified based on severity.  Furthermore, the new criteria are considered to be more thorough.

Q: What autism services and treatments are offered at the Center for Autism and Developmental Disorders at Western Psychiatric Institute and Clinic (WPIC) of UPMC?
A: At WPIC, the Early Intensive Behavioral Intervention (EIBI) Program provides intensive in-home services for young children under the age of 5 and the Theiss Early Autism Program offers in-preschool services. The Merck child outpatient clinic provides diagnostic evaluation, behavioral recommendations, individual, group and family therapies and medication assessment for children and adolescents. There is family-based mental health treatment, an in-school program and summer therapeutic programs.  

In addition, there is a strong emphasis to develop and increase essential services for adults with Autism Spectrum Disorder after the school years (usually after age 21). At WPIC, adults are offered services through the Merck adult outpatient clinic as well as The Vocational Training Center and Supported Employment Program. The development of social competency, employment skills and independence skills are critical to success and an enhanced quality of life.

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