Autism Spectrum Disorders (ASD)
Lauritsen defines autism spectrum disorders (ASD) as a term that encompasses the diagnoses previously referred to as autistic disorders in the DSM-5 ASD, and as pervasive developmental disorders in previous DSM editions. These disorders include Asperger’s, childhood disintegrative disorder, and pervasive neurodevelopmental disorder not otherwise specified (PND-NOS). The author clarifies that in previous DSM editions, ASD had to exhibit itself from early infancy but states that this will change in the fifth edition since ASD deficits may only exemplify itself in later life owing to deficits compensation by guardians in childhood and due to negligible social burdens. An objective of this novel diagnostic criteria is to ensure a consistent ASD criterion that elicits the same diagnosis as the old criteria. She, however, states that the new criteria have numerous limitations including issues with the investigation of its reliability across nations, cultures, and clinicians. There are inconsistency and overlap in the criteria for ASD across sites, with many people either failing to distinguish between the different ASDs (Sharma, Woolfson, & Hunter, 2012). That said, DSM-5 has proposed that distinctions between the ASDs be made based on severity, mental retardation, and the language level.
Onset of ASD
ASD appears in childhood, but numerous studies have shown that ASD can be diagnosed much at a time later than the onset. Moreover, numerous parents and guardians only concede that their kids exemplify early symptoms of ASD when a full-scale diagnosis has been done, and this usually takes long to be done. In addition, it is extremely hard to detect the specific early signs of the disorder, and up to date, no specific symptoms of the disorder have been identified. Due to this arbitrariness in determining the onset of ASD, the novel DSM has scrapped the three years of age limit earlier imposed by previous editions. The decision to scrap the age limit is further accentuated by the fact that in some cases, ASD is only first diagnosed in adolescence or adulthood. The latter phenomenon is explained by the fact that children have minimal social demands, and thus only when the demands for social abilities upsurge later in life do ASD symptoms begin to appear (Lauritsen, 2013).
Language delay has been scrapped from the new DSM criteria since language delay may be present in both children with ASD and those without, and is thus not indicative of ASD. Moreover, some ASD individuals who had language delay issues as kids may develop fluent speech as they age. That said, the development of fluent speech is a pivotal measure of outcome as studies show that severe language delay in childhood is predictive of poor outcomes later in life. Besides, an individual’s language level is utilized in choosing the type of intervention to use. Clinicians also present ASD depending on the patient’s linguistic realm.
Linguistic Malady v. Asperger’s
Lauritsen articulates that there is an ongoing debate concerning the social communication disorders (SCD) subgroup encompassed in the recent classification of communication illnesses. The debate is whether there is a possibility that individuals with Asperger’s may be miscataloged in the social communication disorders subgroup. Such a misclassification would mean that not all persons with Asperger’s in accordance to the DSM-IV classification will be itemized in the same group in accordance to the novel criteria. This further accentuates the classification difficulties articulated in a research done by Sharma, Woolfson and Hunter in 2012. Lauritsen clarifies that this proposal is not in consonance with the novel diagnostic criteria that necessitates all persons with ASD to linger in the same indicative cluster as they were based on the previous editions.
The new diagnostic criteria will also bring further confusion since when Asperger’s patients, for example, suffer from other communication deficits such as speech disorders, they will be diagnosed with ASD as well as the language disorder. Individuals suffering from ASD cannot, however, be detected with SCD as the new DSM-5 criteria stipulate that ASD cannot be analyzed together with SCD.
Population-based studies on ASD have found that social interaction impairments, as well as communication impairments, are part of the same domain, and hence these two domains have been merged to form the social-communication domain. As such, the three domains present in previous DSM editions are now two as in the new DSM-5 edition. The new edition thus contains the social-communication domain and the behavioral domain that contains repetitive behaviors and fixated interests. Further changes have been made to the two domains in the novel edition, with the domains being specifically designated for diverse developmental age groups. The labeling for the clinical representation has also been devolved to include severity of symptoms, the language realm, comorbidity, and the manifestation of erudition disabilities.
Lauritsen states that there are attempts to incorporate disintegrative syndrome into the new DSM classification. The cogency of this syndrome has, however, been hotly contested, especially due to definition issues. There have been numerous problems when it comes to defining developmental regression as well as when regression occurs. Additionally, while some practitioners state that this delayed development was there before regression, others stipulate that the regression preceded the delayed development. There are also two sides to the debate on how changes occur, with some stating that they occur gradually and others suddenly. Due to these difficulties, the novel DSM edition suggests the removal of the category of disintegrative disorder and its inclusion in the wider ASD classification. The DSM-5 suggestion, however, is in contrast with the ICD-11 criterion that makes attempts at defining childhood disintegrative disorder.
The author elucidates how the new DSM-5 edition drives a big push to clarify the ASD diagnostic criteria. This clarification would lead to an upsurge in diagnostic validity especially if these diagnoses were well defined. Lauritsen opines that the new DSM edition will make the ASD diagnostic criteria easier to utilize when it comes to communiqué and communal complications. These two parts are presently problematic to distinguish both in day-to-day life as during assessments in clinics. Excluding the presence of language delay from the novel ASD criterion is expected to lead to a tweak of the diagnostic benchmarks. The decision is also expected not to lead to an upsurge in the number of ASD cases as it is hypothesized that the patients had already been contained within in the unspecified ASD groupings present in earlier DSM editions.
The resolution to remove Asperger’s syndrome from the revised diagnostic criteria has elicited a lot of opposition. However, the suggestion is informed by numerous population and evidence-based studies that show no clear dissimilarities amongst Asperger’s and the other two ASD disorders. These studies have posited that the ASD and Asperger’s criteria overlap, and hence there is no need to classify the two differently. The elimination of Asperger’s syndrome will not only eliminate classification difficulties but also make it easier for clinicians to apply an ASD diagnosis in the new DSM-5 criteria. This is especially so in cases where difficulties have been encountered in collecting data about the early developmental histories of patients due to a poor parental recollection of those issues.
The diagnosis criteria articulated in the DSM are of fundamental importance. Firstly, the criteria standardize the diagnostic process and management of ASD across and within nations. The DSM criteria also aid in informing the assessment methods to be used with ASD patients of varying ages. Numerous national guidelines have been developed and implemented by many countries and institutions, and these all aid in the diagnosis and management of ASD. The application of these guidelines, however, encounter many difficulties especially due to the inadequacy of resources. The American Academy of Pediatrics guideline, for example, articulates how a comprehensive assessment and management of ASD should be performed with the objective of identifying ASD at an early age (Anagnostou, et al., 2014). It stipulates that assessment and identification is the work of child specialists who are conversant with ASD, but due to the lack of specialists, diagnosis is sometimes done by pediatric subspecialists or child psychologists (Lauritsen, 2013).
The UK also has a guideline termed the NAP-C that was developed to ensure a multidisciplinary, multi-agency approach to the diagnosis and management of ASD. The guideline also proffered well-established and used tests in performing these operations, and it has led to the improvement in the diagnostic services for ASD patients. There are, however, differences still being experienced in various diagnostic sites. Just like the NAP-C, the Scottish guideline focuses on clinically assessing and managing treatment and outcomes in kids and young individuals with ASD. It does so by systematically evaluating the methods used and then tweaking them to fit best the circumstance. The NICE guideline works in the same way as the Scottish guideline but fails to include population surveillance and screening mechanisms. It focuses on the comprehensive reconsideration of analysis and management. The New Zealand Autism Spectrum Disorders guideline also works in the same way as those articulated above but has an additional section dealing with specialized erudition and development.
The article offers numerous mandatory provisions for the effective diagnostic evaluation of ASD. One of these provisions is that practitioners need to acquire data on the histories of growth for an individual to determine if the ASD indicators were existent in infancy. This is done by interviewing the parent or guardian of the autistic person. Interviewing also enables practitioners learn about other associated medical disorders. Besides interviewing, practitioners can observe the autistic individual acquire information. Structured observations are particularly popular in Europe and North America. The second mandatory provision is conducting a detailed medical and neurological evaluation designed to rule out associated medical disorders.
The main objective of the intervention exercise is to minimize the dependence of the autistic individual on others by reducing the core ASD features. The intervention exercise also has the objective of facilitating erudition and development as well as improving the skills capability of the individual. This involves eradicating maladaptive and stereotypic behavior. While numerous intervention measures have been applied with great success in autistic individuals, no medical treatment has been found that can completely eradicate the ASD symptoms. Before choosing an intervention measure to apply, the individual’s progress needs determining to acclimate the weights that relatives and other people have on the ASD patient as well as adjust the environment around the person. The people around the autistic individual also need training on how best to support the individual and improve his/ her wellbeing. ASD families are thus pivotal to the planning and outcome of the intervention exercise and thus should be given priority.
There are numerous guidelines available that can be used successfully in the diagnostic and management exercise. Guidelines that present an evidence-based practice such as the novel NICE guideline are recommended. Besides the NICE guideline, the New Zealand guideline is also acclaimed due to its depth of knowledge and clarity of presentation. Nation-specific guidelines are also endorsed since they account for local conditions.
Anagnostou, E., Zwaigenbaum, L., Szatmari, P., Fombonne, E., Fernandez, B. A., Woodbury-Smith, M., & Brian, J. (2014). Autism spectrum disorder: advances in evidence-based practice. Canadian Medical Association Journal, 186(7), 509-519. doi:10.1503/cmaj.121756
Lauritsen, M. B. (2013). Autism spectrum disorders. European child & adolescent psychiatry, 22(1), 37-42. doi:10.1007/s00787-012-0359-5
Sharma, S., Woolfson, L. M., & Hunter, S. C. (2012). Confusion and inconsistency in diagnosis of Asperger syndrome: a review of studies from 1981 to 2010. Autism, 16(5), 465-486. doi:10.1177/136236131141193