How Do I Get an Autism Diagnosis?
by Dr. Kris Robinson, LP
In this guest post, Dr. Kris Robinson explains what exactly is the criteria for diagnosing someone with autism, what changes have happened to the diagnosis criteria over the years, and how those changes have paved way to the removal and addition of disorders that can be officially diagnosed.
Questions and Explanations about the Diagnostic Category of Autism Spectrum Disorder (ASD)
What is the DSM?
The Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5) is the most recent reference guide used by clinical practitioners (psychologists, psychiatrists, therapists, etc.) for the classification of mental disorders. The manual receives periodic updates, which results in some changes. Autism has been a recent area of significant alterations. The following information is obtained from the DSM-5 (reference listed after the article).
What was in the previous DSM pertaining to autism-related issues (like Aspergers and PDD)?
Prior to the DSM-5, the category associated with autism symptoms was entitled “Pervasive Developmental Disorders” (PDD) and included diagnoses of Autism, Asperger’s Disorder, Rett’s Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS). The only difference between Autism and Asperger’s disorders in that manual was the requirement of a language impairment in Autism, which was not included with Aspergers.
So, the previous diagnostic manual’s section appeared like this:
- Pervasive Developmental Disorders:
- Asperger’s Disorder
- Rett’s Disorder
- Childhood Disintegrative Disorder
- Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS)
What changed in the new manual?
A change occurred in the DSM-5 in that Autism, Asperger’s Disorder, and PDD-NOS were merged into one diagnostic category termed Autism Spectrum Disorder. In other words, Asperger’s Disorder, Childhood Disintegrative Disorder, and PDD-NOS are no longer used as diagnoses. For individuals previously diagnosed with one of those conditions, the umbrella term of Autism Spectrum Disorder is to be used. Rett’s Disorder, a discrete neurological, genetic disorder which impacts generally girls, can be listed as occurring with ASD, but does not have a listing in the DSM. It is a separate diagnosis and not a subcategory of Autism. Childhood Disintegrative Disorder was subsumed into ASD, along with PDD-NOS and Asperger’s.
What are the new criteria for Autism?
The most recent diagnostic criteria for Autism Spectrum Disorder are as follows.
Autism Spectrum Disorder 299.00 (F84.0)
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive):
- Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
- Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
- Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive):
- Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
- Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
- Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
- Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).
C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.
What is Social Pragmatic Communication Disorder?
A new diagnosis of Social Pragmatic Communication Disorder has been included and is made when a child experiences significant social communication challenges but not restricted/repetitive patterns of behavior, activities, or interests.
The diagnostic criteria for that disorder include:
Social (Pragmatic) Communication Disorder 315.39 (F80.89)
A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following:
1. Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for the social context.
2. Impairment of the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on the playground, talking differently to a child than to an adult, and avoiding use of overly formal language.
3. Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction.
4. Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meanings of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation).
B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination.
C. The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities).
D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains or word structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder.
What are those codes?
Each diagnosis has a code connected to it. The World Health Organization (and insurance companies) utilizes a coding system of the International Classification of Diseases (ICD). In the DSM-5, both ICD and DSM codes are listed. For example, the DSM code for Autism Spectrum Disorder is 299.00, and the corresponding ICD code is F84.0.
How is a diagnosis really made?
Although the diagnostic criteria are important and useful, case conceptualization must go beyond just the listed symptoms. A comprehensive assessment also includes careful history taking by a qualified professional (generally a psychologist) which devotes attention to social, psychological, and biological domains. A parent/guardian and possibly a teacher may be asked to complete rating scales. Clinical observation of the child is needed. Neuropsychological testing can also be an important component to aiding in diagnostic clarity. A pediatrician or neurologist can provide perspectives as well.
In sum, the latest diagnostic manual has one category pertaining to autism symptoms, termed Autism Spectrum Disorder. The previous category of Pervasive Developmental Disorders (PDD) was removed and most of the diagnoses falling under that PDD category were to be subsumed into and currently diagnosed as Autism Spectrum Disorder. A new diagnosis of Social Pragmatic Communication Disorder, which includes many of the same social communication issues as Autism, was included. Diagnosis, however, goes beyond just a list of symptoms and must involve an analysis of historical information, observation, and caretaker perceptions. Neuropsychological testing as well as consultation with other medical professionals can also be quite beneficial in gaining diagnostic certainty, which then, most crucially, can guide effective treatment.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
About the Author: Dr. Kris Robinson is a Licensed Psychologist who specializes in neuropsychological assessment in her private practice in Lakeway, Texas.
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