The DSM: Diagnostic and Statistical Manual of Mental Disorder.
=>a tool used for communication between clinicians=>until 1973, homosexuality was in the DSM
=>In DSM 1 & 2, autism was not mentioned, but it was mentioned under schizophrenia.
=>In DSM 3+, pervasive development disorders/autism was mentioned (Disorders usually first diagnosed in infancy, childhood or adolescence).
->Disorders usually diagnosed in infancy, childhood or adolescence includes (1)Mental retardation, (2)Learning disorders, (3) Motor skills disorder, (4) Communication disorders, (5) Pervasive developmental disorders, (6) Attention-deficit and disruptive behaviour disorders (7)Feeding & eating disorders of infancy or early childhood, (8)Tic disorders, (9)Elimination disorders, and (10)Other disorders of infancy, childhood/adolescence.
Childhood disorders in DSM-5:
-acquired through brain damage
-happened in developmental stage (that there is no evidence of neurological injury)--abnormal cognitive development (i.e. deviant developmental path)
-one kind of disorder: Pervasive Developmental Disorders (inclusive of Autism, Asperger Syndrome, Pervasive Developmental Disorder not otherwise Specified <PDD-NOS>, Rett's disorder, Childhood Disintegrative Disorder...)
In DSM-4, social features of autism were originally regarded as the triad of impairments (Wing & Gould, 1979). The triad includes three components: socialisation, imagination, and communication.
All autistic people share difficulties as in three aspects, inclusive of socialisation, communication, and restricted interests/repetitive behaviours.
A patient could be diagnosed with autism if there is/are delay(s) or abnormal functioning in at least one of the areas: (1)social interaction, (2) language as used in social communication, (3) symbolic or imaginative play, with onset prior to age 3 years. **The disturbance is not better accounted for by Rett's disorder of Childhood Disintegrative Disorder.
Note:
Rett's syndrome is a rare genetic neurological and developmental disorder that affects the way the brain develops, leading to a progressive inability to use muscles for eye and body movements and speech, which happens exclusively in girls at the age of 6 months old.
Childhood disintegrative disorder is also known as Heller's syndrome/ disintegrative psychosis. It is a rare condition characterised by the late onset of developmental delays/stunning reversals--in language, social function, and motor skills. CDD is a form of regressive autism--where children experience dramatic regression (typically after 3 years of normal development).
DSM-4: triad of impairments
1. Qualitative impairment in social interaction:
- marked impairment in the use of multiple nonverbal behaviours such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
- failure to develop peer relationships appropriate to developmental level
- lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g. by a lack of showing, bringing or pointing out objects of interests)
- lack of social or emotional reciprocity
2. Qualitative impairments in communication (as manifested by at least one of the following):
- delay in/total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
- (in individuals with adequate speech) marked impairment in the ability to initiate or sustain a conversation with others
- stereotyped and repetitive use of language or idiosyncratic language
- lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
3. Restricted, repetitive and stereotyped patterns of behaviour, interests, and activities (as manifested by at least one of the following):
- encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
- apparently inflexible adherence to specific, non-functional routines or rituals
- stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping/twisting/complex whole-body movement)
- persistent preoccupation with parts of objects
In May of 2013, DSM-5 was published. The main changes were the removal of Asperger's syndrome, the combination of social and communication symptoms and the introduction of Autism Spectrum Disorder.
Note:
Asperger's syndrome is a form of milder autism (also characterised by significant difficulties in social interaction and non-verbal communication, along with restricted and repetitive patterns of behaviour and interests), it differs from other forms of ASD with relatively normal language and intelligence. Physical clumsiness and unusual use of language are common in patients. The symptoms usually begin before 2y/o and last a lifetime.
The description and diagnostic criteria have changed for ASD.
1. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest ALL 3 of the following:
- Deficits in social-emotional reciprocity
- Deficits in nonverbal communicative behaviours used for social interaction
- Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers)
2. Restricted, repetitive patterns of behaviours, interests, or activities as manifested by AT LEAST 2 of the following:
- Stereotyped/repetitive speech, motor movements, or use of objects
- Excessive adherence to routines, ritualised patterns of verbal or nonverbal behaviour, or excessive resistance to change
- Highly restricted, fixated interests that are abnormal in intensity or focus
- Hyper-/hypo- reactivity to sensory input or unusual interest in sensory aspects of environment
3. Symptoms MUST be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)
4. Symptoms limit and impair everyday functioning
The criteria for diagnosis changed from triad to dyad, that the previous "socialisation, communication and imagination" triad of impairments was adjusted to the dyad of "(1)social communication, and (2)restricted, repetitive behaviours/interests".
Social communication is inclusive of social communication and interaction; while behaviours refer to restricted, repetitive patterns of behaviour, interests/activities (including sensory abnormalities).
Autism Spectrum Disorder (ASD) was introduced to encompass a range of conditions classified as neurodevelopmental disorders, including autism, Asperger's syndrome, PDD-NOS, and CDD.
The DSM-5 emphasizes on individual needs, which ASD was divided into three levels of severity: (Level1) requiring support, (Level2) requiring substantial support, and (Level3) requiring very substantial support.
The changes were made to refrain the inconsistent use of diagnostic categories by clinicians, and to improve diagnosis without limiting sensitivity. With the new criteria, 91% of previous cases gained ASD diagnosis.
The diagnosis of Autism
According to Bradley-Johnsen et al.(2008), the diagnosis of autism requires three levels of examination.
The first level of the examination was carried out as in interviews and record review. Patients or caregiver will be questioned about the current concerns, how long has been the situation going on, the initiative of seeking help. Additional information would be retrieved from the third party such as school and any circumstances which may concern will be recorded (family functioning, school functioning and/or any recent seemingly unrelated events).
Next, initial screenings will be taken in the form of questionnaire/checklist by clinicians. The screening comes in different methods but they are not intended for diagnosis.
The final level of examination is formal testing, which is inclusive of direct assessment (either autism-related or others), detailed study of case history, behavioural observation and other testings (e.g. neuropsychological, personality, IQ, and comorbidities).
The Autism Diagnostic Interview (ADI-R) (Rutter, LeCouteur & Lord, 2003)
->studies the case history in details
->sturctured interview with parents up to 3 hours
->requires training
->not really useful for adults
->examines the current behaviours and 4-5 years behaviour
->scored by clinician in three subscales (language/communication, reciprocal social interactions and restricted, repetitive & stereotyped behaviours & interests)
The Autism Diagnostic Observation Schedule (ADOS) (Lord, Rutter, DiLavore & Risi, 1999)
->4/5 modules depending on verbal ability/age of individual
->requires training
->individual is put into a series of scenarios in which his/her behaviour is observed
->Young children activities include: responding to their own name, make-believe play with standardised set of objects, joint attention to attention-grabbing toy, demonstrating familiar action (using gesture), telling a story from a book, describing picture etc
->Older children/adults activities include: demonstrating familiar action, telling story from a book, creating a story using objects, interview (about emotions, current work/school, social difficulties & annoyance, friend & marriage, loneliness, plans & hopes) etc
->Participants are scored afterwards based on behaviours observed throughout the activities.
->Take into account both what they say & do and how:
- Aspects of language (e.g. use of stereotyped words, unusual volume/rate etc; offering/asking for information, conversational flow, gesture)
- Aspects of social interaction (e.g. eye contact, facial expressions towards others, empathy, insight into social relationships, quality of close relationships)
- Stereotyped behaviours (e.g. excessive interest in certain topics, compulsions & rituals, hand & finger mannerisms, unusual sensory interest in items)
Some other formal testings:
>Behavioural observation
->Psychiatrist: interaction, screening, observation
->Psychologist: neuropsychological tasks, personality tasks (sentence completion/drawing/storytelling), IQ tests, comorbidities, ToM
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