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The Proposed Elimination of Asperger's As a Legitimate Medical Diagnosis
by Gary M, Eisenberg, Ph.D.,Child Psychologist, Boca Raton, FL
The American Psychiatric Association is currently in the process of revising the diagnostic and statistical manual to its newest version, DSM-V, slated to appear in 2013. Along with many recommendations is one to delete the term Asperger's Syndrome and subsume it under Autism Spectrum Disorder.
The APA states that Asperger's Syndrome was originally proposed to stimulate research. That, indeed, it has. However, it is the current strong proposal to eliminate Asperger's, as well as other ASD diagnoses, as legitimate medical diagnoses.
The principle APA rationale is that Asperger's cannot be reliably differentiated from high-functioning autism. In other words, an autistic individual with a stronger IQ and good language is not significantly different than an Asperger's individual. They still have in common (A) deficits in nonverbal and verbal communication as used for social interaction, (B) lack of social reciprocity, and (C) failure to develop and maintain peer relationships. Additional ASD criterion also includes restricted and repetitive patterns of behavior, interests and activities.
The APA further complains that Asperger's Syndrome is a term used very loosely with little agreement. They said a recent study showing that only 44% of current diagnoses actually concur with current DSM-IV criterion.
Furthermore, high-functioning autism and Asperger's are very similar in the course of the disorder, cause, and treatment.
In short, students formerly called Asperger's Syndrome or Asperger's Disorder will now be considered to be on the Autism Spectrum Disorder and described by dimensions. The dimensions have yet to be fully fleshed out by the APA, yet they suggest at least two would be IQ and language ability. So what was Asperger's Syndrome will now be Autism Spectrum Disorder with above-average IQ and strong language (criterion to be settled or proposed later).
Not only is Asperger's out, but Childhood Disintegrative Disorder would be removed. Childhood Disintegrative Disorder currently refers to a small subgroup of autistic individuals who initial trajectory was toward normal development. At some point they stopped developing or perhaps regressed.
The APA, from their website dsm5.org, cites that "regression is not a dichotomous phenomenon and many children with autism undergo a loss in skills at one time or another…" This means that autistic children cannot be split into a regressive versus a nonregressive group.
So indeed again, these children will be assumed under the Autism Spectrum Disorder label but now be discussed in terms of their trajectory. In other words, their developmental trajectory could be typical or normal up until age two or possibly three.
Lastly, the catchall term for those on the spectrum, Pervasive Developmental Disorder Not Otherwise Specified, will also be eliminated or more rarely used. It is this psychologist's opinion that PDD-NOS has been overused this last decade. That is because there are so many children who do not fit in the classic autism diagnosis as well as the Asperger's one. Hence, PDD-NOS has become the catchall category. There have been multiple attempts to define PDD-NOS, but in short it is a category of exclusion. That means it is principally used when children do not fall into other categories.
Parents and professionals have been very concerned about these changes in autism diagnosis. Although the American Psychiatric Association's assertion is true that it is indeed difficult to differentiate Asperger's from high-functioning autism, this psychologist has grave concerns about eliminating the term Asperger's Syndrome from current nosology.
For so many children it is a great "fit." Now with so many years of Asperger's research and clinical experience, Asperger's children are gaining "respect." They are now thought of as intelligent children with great potentials due to their memory and factual abilities. At times they are even desired employees. Now there is a wealth of knowledge available about treating their behaviors, raising Asperger's children, and even marrying Asperger's spouses.
The APA proposes that those of whom feel now disenfranchised by the loss of Asperger label could still refer to themselves as Asperger-like.
Yet it is this psychologist's opinion that many parents seeking professional help may avoid same if they believe the ultimate diagnosis might be autism. Parents have now become much less defensive about the Asperger label.
This psychologist would propose that the syndrome be split into two. That is that Autistic Disorder would principally be for the lower-functioning children. The former PDD-NOS plus current Asperger's Syndrome children should be subsumed under the Asperger label, which would also include "high-functioning autism." The same "dimensions" proposed by APA to differentiate Autism Spectrum Disorder could be used to differentiate Asperger's from ASD. That is, it would be very easy to develop an IQ criterion plus a descriptive language criterion to differentiate the two. Furthermore, stereotypical or repetitive behaviors tend to be more verbal in the Asperger's group, versus more motor in the autistic group. This and other symptoms can also be used in the differentiation.
The loss of the Childhood Disintegrative Disorder has not as many impacts for diagnosis as it does for treatment. That is, the mere existence of autistic regression implies that somehow normal children reach a "tipping point" in which environmental toxins and body chemistry somehow overwhelm the gastrointestinal system and brain to cause autistic regression. Research is very much focusing on environmental contributions to autism. There has already been very good research supporting that the following contribute to autism: Pesticides and heavy metals such as mercury. Although an area of suitable controversy, there is an indication that medicines and vaccines can also play a role in autistic regression, although in only certain vulnerable children.
Hence, this psychologist would not want to lose a diagnosis that could easily point the way toward emiliorating the autism phenomenon. One hopes that in the future we will be able to protect our children's bodies from these environmental toxins. Once discovered, there are multiple ways of detoxifying children's bodies. The American Psychiatric Association currently is not accepting comments on their proposed changes. However, there are many months for which they did. Many protested the loss of the Asperger's label; let us hope they listened.
Gary Eisenberg, Ph.D., is a child psychologist in private practice in Boca Raton, FL. Learn more about him on : Dr. Eisenberg's ISER listing.
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