Autism Spectrum Disorder - Research Paper Example

? Autism Spectrum Disorder: Changing the Patterns of the Due Autism Spectrum Disorder: Changing the Patterns In psychiatric diagnosis, the Diagnostic and Statistical Manual of Mental Disorders, or DSM, developed by the American Psychiatry Association (APA) consists of the classification criteria and nomenclature used to achieve a universal understanding of terms between members of the healthcare team involved in the management of individuals with mental disorders. Over the years, the DSM has been revised while some of its sections completely rewritten as new empiric evidence gathered through research continually challenge its existing definitions as well as provide potentially more efficient ways of management (Leventhal, 2012). One important revision in the fourth edition that will be evident in upcoming release of DSM-V involves the reclassification of three pervasive developmental disorders into a more inclusive term Autistic Spectrum Disorder or ASD (APA, 2012). This paper will primarily discuss the rationale and opposing arguments for this change and implications on the management of these disorders. Autistic Disorder in the DSM-IV The DSM-IV defines pervasive developmental disorders (PDD) as conditions that present as problems affecting social interaction, language development and usage, and behavior of individuals. Currently, this classification includes autistic disorder, Rett's disorder, childhood disintegrative disorder, Asperger's disorder, and pervasive developmental disorder not otherwise specified or PDD-NOS. Each of these diagnoses is distinguished from the rest through specific characteristics and severity (Autism Research Institute, 2013). Specifically, the diagnosis of autistic disorder as directed the DSM-IV is used only if there are qualitative impairments in social interaction, impairment in communication, and restricted repetitive and stereotyped patterns of behavior or interests. The constellation of these clinically discernible signs practically creates a triad of domains that need to be satisfied to make the diagnosis. Two manifestations particularly related to the impairment in social interaction should be present including either a noticeable impairment in the utilization of multiple nonverbal behaviors (i.e. eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction), inability to develop relationships with peers in congruent to the developmental level, absence of spontaneous seeking to share enjoyment, interests, and achievements with other people, or a lack of social or emotional attachment and reciprocity (APA, 2000). Furthermore, one communication problem must be manifested. It can either be a delay or a total absence of a language. In the case when language has already been established, the autistic individual may show inability to sustain the conversation. Stereotyped language may also be present. Social imitative play may not be apparent in children with autistic disorder. At least one manifestation in the domain of restricted repetitive and stereotyped patterns of behavior or interests (RRB) is required for the diagnosis of autistic disorder in the DSM-IV. It can either be in the form of a useless ritual, preoccupation with inanimate objects, presence of mannerisms, or restricted interests (APA, 2000). Moreover, the DSM-IV requires that at least one in the three domains should show the impairment prior to the age of three. Other possible conditions like Rett’s disorder and childhood disintegrative disorder should be ruled out as these conditions also manifest similarly to autistic disorder, only with a few excluding features (Sadock & Sadock, 2007). Rationale for Changing DSM-IV Changes for the DSM-V aim to provide more specific, highly sensitive, precise, and reliable criteria for the diagnosis of ASD by particularly addressing the possible areas of ambiguity (Autism Research Institute, 2013). While continuous revisions have been undertaken in the DSM-IV several years after it has been published, the diagnosis of autistic disorder and other pervasive developmental disorders constantly meets new challenges as changes in the progression of the disorder vary widely in the population (Mattila, Kielinen & Linna, et al, 2011). Given adequate support and strict adherence to therapy, some autistic children successfully integrate with the community and develop competence at par with age group. At the contrary, autistic individuals may also experience a progressive decline in function and productivity when their special needs are not met (Sadock & Sadock, 2007). Interestingly, individuals who have been diagnosed as having Asperger’s disorder or PDD-NOS also develop similar positive or negative consequences with those who have autistic disorder depending on the quality of therapeutic support they receive (Szatmari, Archer & Fisman et al, 1995). This means that the demarcation between the three PDDs at the time of diagnosis may change and create confusion on the present validity of the diagnosis (APA, 2012). In fact, results of epidemiologic studies confirm that several mental health practitioners may have contradicted each other at some point as the establishment of a working diagnosis is concerned despite having the guidelines in the DSM-IV (Mattila, Kielinen & Linna, et al, 2011). For instance, Asperger’s disorder can only be differentiated from autistic disorder by determining whether a significant impairment in language development and usage, and delays in cognitive development and self-help skills appropriate to age is seen in an individual (Szatmari, Archer & Fisman et al, 1995). Individuals with Asperger’s disorder do not manifest such impairments although social interactions and patterns of behavior and interests clearly show signs of abnormality. Thus, individuals with Asperger’s disorder can be extremely similar to those diagnosed with high-functioning autistic individuals (Sadock & Sadock, 2007). Likewise, the criteria for the diagnosis of PDD-NOS can be confusing as some clinicians attempt to classify an individual under a specific diagnosis or correlate manifestations to satisfy a criterion (APA, 2012). The definition of PDD-NOS as a severe and pervasive abnormality in communication skills or presence of impairment in behavioral patterns and interests create an ambiguity as affected individuals may show an improvement in behavior as therapy is instituted (Sadock & Sadock, 2007). Although the differences between the three PDDs seem clear at the time of diagnosis, changes that occur to the affected individuals as different therapeutic approach are utilized can pose an important question on the precision and validity of the diagnosis at present (APA, 2012). Revisions for the new DSM aim to eliminate this confusion by combining the three instead into a more collective term Autism Spectrum Disorder (ASD). In addition, the approach of the DSM-V forms a graduated spectrum which specifies manifestations according to severity of disability. The three PDDs can be practically seen as a cluster of symptoms classified as autism which differ only to the degrees of severity and disability (Leventhal, 2012). When patients improve, the status can simply be adjusted in the spectrum. Besides, autism is a set of behaviors in which observed manifestations may vary with each individual case at a specific time frame (APA, 2012). Autistic Spectrum Disorder in DSM-V The proposed revisions for the DSM-V on the criteria for the diagnosis of autistic disorder reduce it to two main domains such that Communication and Social Reciprocity domains will be combined (Frazier et al, 2012). As a result, the autism triad will be replaced by autism dyad composed only of Social/Communication Deficits and Restricted Interests and Repetitive Behaviors (RRB) (APA, 2012). These changes override the classical diagnostic criteria of Asperger’s disorder and PDD-NOS that cause the removal of both labels in the new DSM (Autism Research Institute, 2013). As a result, autistic disorder, Asperger’s disorder, and PDD-NOS will be classified as ASD assuming that the newly rearranged specific criteria under the two domains remain satisfied in individual cases (APA, 2012). Delays in language development and impaired imagination are removed from the criteria for the diagnosis of ASD while the use of stereotyped language is redirected as a sign under RRB domain (Mandy, Charman & Skuse, 2012). Nevertheless, the new set of criteria is more stringent so that individuals previously diagnosed with any of the three PDDs may not fit to the ASD in the DSM-V. Prior to the official release of the DSM-V, proposed changes in the criteria for ASD diagnosis have been subjected to scrutiny. In a study conducted to verify the validity of the draft DSM-V, Confirmatory Factor Analysis (CFA) was used to compare alternative models including the DSM-IV. Results showed the relative superiority of the dyadic criteria in DSM-V compared with the triad of domains in the previous DSM (Mandy, Charman & Skuse, 2012). In addition, sensitivity and specificity can be further increased by relaxing the domains, redirect, or reduce the number of clinically observable manifestation required to satisfy a domain (Frazier et al, 2012). With the shift to reduce the number of domains into two by combining social and communication areas, the resulting set of criteria for diagnosis proved to be more stable across age and gender (Leventhal, 2012). Aside from this, the removal of the delays in language development and absence of imitative play covered more individuals to qualify for ASD diagnosis (McPartland, Reichow & Volkmar, 2012). Basically, changes in the diagnosis of ASD to be seen in the DSM-V create more precise criteria, thereby ensuring a reliable and valid diagnosis. Problems with the DSM-V Criteria Most of the results of studies conducted to validate the reliability of the criteria for ASD diagnosis in the draft DSM-V confirm its superiority than the previous edition (APA, 2012). Even so, certain issues about these changes remain to be considered. An important argument that opposes changes is that treatment opportunities might be missed when dealing with a broader diagnosis. Modern understanding of the three PDDs included in the ASD reveal that distinct features related to their severity remain to be present (Mattila, Kielinen & Linna, et al, 2011). When each diagnostic label is dealt with individually, certain features may unravel potential points of management. Individuals with Asperger’s disorder, for example, have normal intelligence and cognition unlike the other PDDs. Thus, it can be practical when the disorder is managed in a different way than by a common approach in ASD (Szatmari, Archer & Fisman et al, 1995). Furthermore, vital information on the variables that contribute to the development of the disorder other than cognitive, behavioral, and social factors may vary greatly with each disorder. For instance, the etiology for autistic disorder is seen to involve certain genetic, biological, immunological, perinatal, neuroanatomical, and biochemical factors (Cicchetti & Cohen, 2006). Obnoxious events such as maternal bleeding in the perinatal period, intrauterine infection, and longer than usual period of pregnancy among others, can also cause autistic disorder (Szatmari, Archer & Fisman et al, 1995). Prevention of these events can possibly reduce the incidence of autistic disorder. While studies in Asperger’s disorder reveal that its etiology may be similar with autistic disorder which recognizes the influence of biological factors, the exact mechanisms of the causation can be very different. The effect of different infectious diseases may be unique in each of the PDDs (Cicchetti & Cohen, 2006). On the other hand, PDD-NOS may be considered as a premature account of a more specific mental disorder although the combined manifestations may not yet evident at the time of diagnosis (Sadock & Sadock, 2007). Combining the three PDDs will dismiss chances that certain biological causes may be involved in the development of the symptoms. In fact, the degree of exposure to such factors may open up possible explanations on the differences in severity of symptoms and disability. Understanding the etiologic and pathologic mechanisms strengthens the use of psychopharmacologic approach to care (Sadock & Sadock, 2007). Implications for Management The different outlook on each PDD in the DSM-IV provided several approaches to care. Individuals diagnosed with Autistic disorder receive scrupulous cognitive-behavioral therapy that target maladaptive behaviors (Sadock & Sadock, 2007). Many resources are available as the state and educational services recognize their role in maintaining well-being of these individuals. In contrast, the diagnosis of Asperger’s disease does not usually warrant special education since these individuals do not present major problems with their intelligence and cognitive functioning (Szatmari, Archer & Fisman et al, 1995). Individuals with PDD-NOS receive similar approach with autism but with lesser emphasis on language and self-awareness skills. Imminent changes for the DSM-V uncover legitimate issues on how the individuals diagnosed with any of the PDD will be managed in the future (Autism Research Institute, 2013). Due to a number of revisions in the diagnostic criteria, it is possible that some individuals who previously belonged to any of the diagnostic classification of PDD will not be covered in ASD (McPartland, Reichow & Volkmar, 2012). That is, access to appropriate healthcare services might be limited as the insurance companies and educational services often rely on the diagnostic label indicated by the clinician (Autism Research Institute, 2013). Nevertheless, the exact impact of these changes on the management of individuals with ASD is yet to be determined. Even if the criteria may have been clearly laid out in the DSM-V, differences in judgment and opinion among mental health practitioners will ultimately cause considerable disparities in diagnosis and treatment (Mattila, Kielinen & Linna, et al, 2011). Formal discussions among healthcare personnel and other stakeholders have to be formed in order to reach a common understanding of these changes (Autism Research Institute, 2013). Analysis and Conclusions As the quest to solve the puzzle of mental disorders is underway, more knowledge brought about by research studies mold the current standards of diagnosis and treatment. In the comprehensive approach to the management of diseases including mental disorders, appropriate criteria need to be set-up to achieve a universally acceptable diagnosis (Mattila, Kielinen & Linna, et al, 2011). Unlike diseases with biological and pathologic mechanisms, the manifestations of mental disorders vary greatly in severity and overall effect in an individual’s productivity. The proposed changes in the criteria for the ASD diagnosis lumps autistic disorder, Asperger’s disorders, and PDD-NOS into one diagnostic label called Autistic Spectrum Disorder (ASD). After comparison with several existing tools, the revisions have successfully held out the inconsistencies and proved to be highly reliable, more precise, and therefore compose a valid tool for diagnosis (Frazier et al, 2012). Several research studies reproduced same results comparing the draft DSM-V with other existing diagnostic tools for autistic disorder (Autism Research Institute, 2013). Actually, the revisions do not represent a total crackdown of the existing criteria. Essentially, only minute redirections and a few addition and subtractions were made for the draft DSM-V. However, the results guarantee a major change in the way we look at PDDs (Leventhal, 2012). Management of the conditions greatly change the patients’ access to available resources and support as their diagnoses were once the basis for the allocation of their basic services. On the other hand, these changes reveal some of the loopholes in the management of mental disorders. Specifically, the diagnostic criteria consider only the psychosocial manifestations of the disease such as those that involve social reciprocity, communication abilities, and behavioral patterns. While attempts have been performed to unify specific ways that clinicians consider a manifestation, psychosocial manifestations remain to be very subjective (Cicchetti & Cohen, 2006). Specific time frame, mood, emotional involvement, and other individual factors affect the extent to which the symptom is demonstrated in an individual. The problem is apparent in virtually all mental health disorders not only ASD. Different mental health professionals may diagnose the same constellation of symptoms as different disorders, thus creating significant inconsistencies in the reporting of incidence and prevalence of specific cases (Leventhal, 2012). Furthermore, hastily and carelessly relying on the diagnostic criteria specified in the DSM may increase the rates of misdiagnosis, false-positives, and false-negative diagnoses. Hopefully, new objective ways to diagnose mental disorders will be developed in the future. As the biological and pathophysiologic aspects of mental disorders are continually studied, diagnostic techniques may not rely solely on observed manifestations (Cicchetti & Cohen, 2006). Physical and laboratory tests may prove value when the exact mechanism of the disorders can be plotted. Regardless of the final diagnosis of the patients, it should be clear that the frameworks provided in the DSM do not supersede sound judgment by the mental health professional. Each patient is unique. While there are cases when some patients extremely resemble another, individual factors interact to cause a certain degree of peculiarity. Therefore, the management of diseases should always be aimed at individual needs. References American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4th Ed.) Washington, DC: American Psychiatric Association. American Psychiatric Association (2012). DSM-5 Overview: The Future Manual. Retrieved from http://www.dsm5.org/ Autism Research Institute (2013). Updates to the APA in DSM-V – What do the changes mean to families living with Autism? Retrieved from http://www.autism.com/ Cicchetti, D. & Cohen, D. J. (2006). Developmental Psychopathology (2nd Ed.). New Jersey: John Wiley & Sons. Frazier, T. W., Youngstrom, E. A., Speer, L., Embacher, R., Law, P., Constantino, J., Findling, R. L., Hardan, A.Y. and Eng, C. (2012). Validation of Proposed DSM-5 Criteria for Autism Spectrum Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51 (1): pp. 28-40. DOI: 10.1016/j.jaac.2011.09.021 Leventhal, B. L. (2012). Lumpers and Splitters: Who Knows? Who Cares? Journal of the American Academy of Child & Adolescent Psychiatry, 51 (1): pp. 6-7. DOI: 10.1016/j.jaac.2011.10.009 Mandy, W. P. L., Charman, T., and Skuse, D. H. (2012). Testing the Construct Validity of Proposed Criteria for DSM-5 Autism Spectrum Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51 (1): pp. 41-49. DOI: 10.1016/j.jaac.2011.10.013 Mattila, M. L. Kielinen, M., Linna, S. L., Jussila, K., Ebeling, H., Bloigu, R. and Moilanen, I. (2011). Autism Spectrum Disorders According to DSM-IV-TR and Comparison With DSM-5 Draft Criteria: An Epidemiological Study. Journal of the American Academy of Child & Adolescent Psychiatry, 50 (6): pp. 583-592. McPartland, J. C., Reichow, B., Volkmar, F. R. (2012). Sensitivity and Specificity of Proposed DSM-5 Diagnostic Criteria for Autism Spectrum Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51 (4): pp. 368-383. Sadock, B. J. & Sadock, V. A. (2007). Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (10th Ed.). New York: Lippincott Williams & Wilkins Szatmari, P., Archer, L., Fisman, S., Streiner, D. L. and Wilson, F. (1995). Asperger's Syndrome and Autism: Differences in Behavior, Cognition, and Adaptive Functioning. Journal of the American Academy of Child & Adolescent Psychiatry, 34 (12): pp. 1662-1671. Read More