Asperger’s, Autism & the New DSM

Sometimes it’s easy to understand why a certain diagnosis is considered an educational disability, and sometimes it’s easy to understand what needs to be done to help. In other cases, such as that of Asperger’s Syndrome, it’s not so simple. Asperger’s Syndrome is an autism spectrum disorder (ASD), as are autism and Pervasive Development Disorder NOS, that is characterized by substantial difficulties in social interactions, as well as repetitive and restrictive patterns of behavior and interests. It is reported that as many as 1 in 90 people are diagnosed with ASD, most in childhood, but with many escaping diagnosis until young adulthood or even beyond.

Though it is part of the autism family, it differs from most of the spectrum in the lack of negative effect on verbal communication and cognitive development. In most cases, people with Asperger’s have the ability to intensively focus on a task for long periods of time, blocking out all distractions and allowing them to dedicate all of their brainpower, which can be a benefit to classwork. It’s these latter aspects that make definition as an educational disability a debated topic, and make accommodations harder to understand.

There is a common belief that people with Asperger’s are always highly intelligent, though studies have not been able to show this conclusively. Often these studies instead show that the occurrence of higher intelligence is the same as that of the general population. There are arguments that these results are found only because intelligence tests are not a valid measure for the autistic population, one that has a marked disadvantage taking standardized tests. Whichever may be true, the fact of the matter is that many people with Asperger’s, especially those who are attending college, will tend to have very good grades, possibly due to the ability to focus intensively on the task at hand, and/or a possibility intelligence. It’s this good general academic performance that leads some to believe that Asperger’s is not a educational disability.

To understand why Asperger’s can be an educational disability, it is best to look at a couple of examples. Student A studies physics, and has an amazing aptitude for the material, spending his days intensively focused on equations and theories. He has poor grades and no idea he is in trouble, that is, until he fails the class. Why? Because he was so focused on the material, he missed class a lot, didn’t understand why this bothered his professor, and didn’t understand a possibly vague attendance policy. Without the help of someone to remind him to go to class, to take breaks, and maybe even eat, he risks throwing his abilities out the window. This of course is a somewhat extreme example, but highlights how an educational disability may not be what we imagine as a traditional “learning” disability.

You may be more likely to encounter Student B. Because of her ability to focus on her studies, she absorbs textbooks like a sponge, and has a brilliant understanding of all of her course material. She too however, is at risk of failing. In her case, she does poorly on exams because she, though knowing all of the answers, is unable to sit through a written examination due to her Asperger’s symptoms.

These are just examples of what you may see in students with Asperger’s Syndrome, and are no way exhaustive. Each student will vary, from those who may have little or no manifestations, to those who have issues with many aspects of everyday life. Therefore, whether or not Asperger’s Syndrome is viewed as an educational disability, requiring proper accommodations, will be dependent upon a thorough review of each individual case. It is important to remember that some people with this disorder will not realize they are having problems that require help.  If you or someone else suspects that a student may be having problems, you can contact Disability Services with questions.

College Professor's Guide to Understanding Asperger Syndrome Part I

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College Professor's Guide to Understanding Asperger Syndrome Part II

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Proposed Changes to Autism Spectrum Disorders in the New DSM

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is multi-disciplinary manual published by the American Psychiatric Association (APA) that contains the standard criteria and terminology for the classification and diagnosis of mental health disorders. The DSM was first published in 1952 and has undergone four revisions since, with the last revision (DSM-IV) published in 1994. After nearly twenty years without more than a textual revision in 2000, a new version of the DSM is slated for publication in 2013.

As with prior revisions, this version is currently in a commenting and critiquing stage, but for the first time, thanks to the widespread use of the internet, the content of this revision is available on an APA website for public viewing. In this way, the public – and perhaps patients themselves – can learn about these revisions ahead of time and make their opinions on changes heard.

One of the major changes to the DSM is the merging of autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDDNOS) into what will possibly be known as the Autism Spectrum. The new criteria are simplified from the DSM-IV criteria for autistic disorder and are three-fold.

  • Firstly, there must be clinically significant, persistent deficits in social communication and interactions, as manifested by marked deficits in nonverbal and verbal communication used for social interaction, lack of social reciprocity, and a failure to develop and maintain peer relationships appropriate to developmental level.
  • Secondly, there must be restricted, repetitive patterns of behavior, interests, and activities. This must be manifested by at least of the following: stereotyped motor or verbal behaviors, or unusual sensory behaviors; excessive adherence to routines and ritualized patterns of behavior; or restricted, fixated interests.
  • Finally, symptoms must be present in early childhood, but may not become fully manifest until social demands exceed limited capacities.

The diagnoses in the DSM-IV show much more variance and detail between each differentiation. Currently the APA has not defined any criteria for how severity will be determined, though this is included somewhat in the Report of the DSM-V Neurodevelopmental Disorders Work Group (2009). The website does say that this recommendation is forthcoming and may provide more insight into the revised diagnosis.

The rationale for this change is not rooted in diagnostic differentiation between autism spectrum disorders and “nonspectrum” disorders as the discrimination between the two groups has been done validly and reliably. The problem, according to the APA, is the differentiation within the diagnoses on the spectrum, which have proven inconsistent temporally and geographically. Often times these differences appear to be associated with the severity, level of intelligence, and linguistic capabilities rather than any practical features of the existing labels.

The APA feels that, due to the common set of behaviors that appear within all diagnoses, the single spectrum diagnostic model is a best fit to our current understanding of pathology and presentation of the disorders. The new model will be adapted to individual presentation by the use of clinical modifiers (verbal abilities, severity, etc.) and the associated features of each patient (such as possible genetic disorders, comorbid disabilities or medical conditions, etc.).

Since the proposed DSM-5 was published online, there has been a great deal of public debate on the issue. The most discussion, and perhaps the most controversy, has been over the disappearance of the Asperger’s diagnosis. For years, many researchers and medical professionals have already referred to Asperger’s Syndrome as high-functioning autism, or a form thereof. However, until now, the diagnosis hadn’t been listed under the category of autism. Since the publication of the DSM-IV, the line between Asperger’s and autism has been ever moving, with health care professionals struggling to find a way to differentiate between the two diagnoses. Oftentimes, established separation criteria prove inadequate or incorrect when applied in practice, though often diagnosis is based on the linguistic capabilities on the individuals.  One problem with this is that linguistic abilities can change over time, and assessment is often subjective.

Therefore, some feel the change will allow doctors to spend more time focusing on the details and specifics of the individual’s presentation and developing a way to improve his/her life, rather then spending too much time trying to decide which diagnoses is the most correct.  As one father of an autistic child, and an anthropologist at George Washington University who has studied autism in various cultures, said, “As somebody who has a child with a diagnosis of autism, I want to be able to turn to the official criteria and see a description that sounds like my child, right now my child sounds like three or four different disorders” (source).

Another pro-change argument states that the change does not prevent anyone from receiving treatment and services, and in many cases may actually improve these opportunities. This is because some states, such as California, provide services to children with autism but not those with Asperger’s, so the proposed changes would in effect be removing what could be seen as an arbitrary separation from services to certain individuals qualified to receive them.

Though the above argument may be true, it is important to remember there is another side to this debate. Some fear that the change will marginalize severely autistic individuals because as they currently stand, there is no explicit mention of intellectual disabilities in the criteria, only in the rationale.  The Report that accompanied the proposed DSM revisions appears to further ignore this aspect by listing subcategories of normal variation, subclinical symptoms, less severe, moderately severe, and most severe.

This represents a further broadening of the spectrum at the high functioning end, with the first two categories representing typical variations in human behavior and personality (i.e. no significant interference or impairment).  These parties believe that this will minimalize the perception of the possible severity of the disorder, as it would make it appear that not many people would have a “most severe” diagnosis.  Hopefully, however, this will be addressed and clarified by official recommendations on severity criteria.

A second argument is centered on public perception of the disorders, and a fear by patients and parents of patients that the change from an “Asperger’s” diagnosis to an “autistic” diagnosis could affect the way they are treated.  Many fear that they, or their children, will be a labeled and pigeonholed by those who do not know them, or are first meeting them.  This group also recognizes the high number of autistic individuals who have comorbid intellectual disabilities, and worry that the grouping of the diagnoses may change the perception of formerly individuals formerly diagnosed with Asperger’s .

Many also see the Asperger’s diagnosis as a part of their identity, especially those who have lived with the label for many years.  By grouping all spectrum individuals together, they fear they will lose this, as they will not be able to relate or identify with a majority of their autistic peers under the new criteria.  Though many will admit that there are more service options for people, especially educationally, with autism, they also feel most are not appropriate for individuals with Asperger’s.  This is because along the spectrum, there are differences in abilities and working treatment options for helping these individuals.

Hopefully, such a public critique of the new revisions will finally give us a revision of the DSM that will be more accepted and understood.  Those on the task force for evaluation of the proposed changes should look highly towards the concerns of those against the changes and work to make sure they are properly addressed.  Hopefully by the publication in 2013 a consensus will be met making sure this change is the best possible move for both clinicians and patients.

Resources

APA – DSM 5

NPR – Asperger’s Officially Placed Inside Autism Spectrum

Facing Autism in New Brunswick

CNN – Move to merge Asperger’s, autism in diagnostic manual stirs debate