This is going to be a long and potentially controversial post.
To those of you who are not autism mamas, you're probably looking at the title of this post and thinking, "DSM-5? WTF?" No worries, I'll give a little background before I launch into this.
The Diagnostic and Statistical Manual of Mental Disorders, known as the DSM, is the "Bible" by which doctors get the criteria for diagnosing children and adults with a variety of conditions, including all autism spectrum disorders. Currently, the DSM is in revision IV, so you'll hear people refer to the current version as the DSM-IV. The proposed update to the DSM will be revision 5, thus the DSM-5, which is likely to roll out in May of 2013.
Of concern (besides the fact that neurodevelopmental disorders are still lumped into the classification of "mental disorders"...but I digress) is
the proposed changes to the diagnostic criteria for ASDs. In particular, here is what the DSM-5 will do:
- Eliminate Asperger's Syndrome and PDD-NOS (what Jack is technically diagnosed with) and lump them with autistic disorder into a new diagnosis called "autism spectrum disorder".
- Change the diagnostic criteria for "autism spectrum disorder."
- The addition of a severity "grading" scale.
On Friday, I joined in on a Live Webchat with Dr. Geri Dawson and Lisa Goring of Autism Speaks as they attempt to address the panic that resulted following the release of a
New York Times article on Thursday that suggested that many individuals on the autism spectrum would be excluded from the new DSM-V definition. While I normally am a big advocate and fan of Autism Speaks, I feel as though they could be a bit less ambiguous in their answers to questions that will greatly impact the lives of the millions of people for whom they advocate. I felt the ambiguity simply leads people to make incorrect assumptions for themselves.
That being said, I really feel there is no need to panic. Seriously.
First, I believe the study to be seriously flawed. I am a big fan of reading primary sources and abstracts, and yet I have not found a single place in which the study in question has actually been published. It hasn't undergone peer review. In that regard, I don't consider it valid...yet.
Volkmar, the author of the analysis, was at one point on the APA committee, but then resigned. After that, this analysis comes out. Is that the result of Volkmar disagreeing with the committee? Possibly. Is it the result of Volkmar leaving with a bad-taste in his mouth? Possibly. I think that scientific bias must always be considered when evaluating the validity of studies which, through design, can be made to say anything. After all, scientists are people, too.
Aside from that, I believe the study design to be flawed as well. From my understanding, the study assesses the patient records - not the patients themselves - to determine whether or not they meet the DSM-5 criteria. Why is this wrong? Because doctors are human. They don't write down every fact, every quirk, every nuance that they see in a patient. Believe me, when I go to Dr. DP with my list of comments and concerns, it's PAGES long. That's not everything, either. A doctor might take all of these details into account when making a diagnosis, yet they may not record all of it. Thus, patient records lack critical pieces of data reflecting a patient's condition.
In addition, the data used was from a very narrow group of individuals - those who are particularly high-functioning. Thus, applying blanket statements like "many individuals will be excluded" are simply not applicable because it doesn't take into account a demographic representative of the entire ASD population. To do so, one would need to look at all levels of functioning, not just the highest of the high-functioning.
Also, the data he uses is from 1993. That's nearly 20 years ago! Our understanding of ASD and the way doctors evaluate and examine it has changed drastically since that time. Aspects of ASDs that are considered in the new DSM-5 might not have even been considered by the doctors assessing these patients in the early 90s. It's not that the patients didn't necessarily have these characteristics, but that they weren't considered relevant to the patient's ASD diagnosis. For example, much more weight is placed on sensory issues these days. A patient with sensory processing problems in the early 90s might have demonstrated sensory issues, but a doctor might not have considered it critical to the ASD diagnosis. So what does he do? He doesn't include it in the patient records because it's just another "quirk" of that particular patient. In the new DSM-5, sensory processing issues are considered one of the behavioral criteria, but a researcher might conclude that a patient in 1993 did not have this issue if it weren't included in the patient record.
While I am bothered by the passing off of pseudo-science as actual peer-reviewed science, I am incensed by the following quote from the New York Times article, as stated by Dr. Fred Volkmar, the author of the analysis in question in the Times article. He claims that the "changes would narrow the diagnosis so much that it could effectively end the autism surge." He goes on to say that we "would nip it [the autism surge] in the bud."
This is dangerous territory we're going down here.
My son has a neurological disorder. Suppose someone decided tomorrow that the diagnostic threshold for cancer was not stage 1 cancer, but what might be considered stage 2? Everyone with stage 1 cancer might lose insurance coverage for treatments such as chemotherapy, radiation, and surgery. Insurers decide what is "appropriate treatment" based on the diagnosis code provided. There would be an uproar among patients. Suddenly, you would have to be more severe to get treatment. It might also effectively "win" the war on cancer.
Or, better yet, imagine if our country could simply lower the poverty line. Suddenly, millions of people might not qualify as living below the federal poverty level and thus might not qualify for social services. Would that reclassification mean that those people don't struggle? Of course not.
This is what many parents perceive is happening with the DSM-5 revision.
The fact that a body of psychiatrists can debate and alter what we define as autism does not make a single one of the people who currently have diagnoses not autistic. Call it whatever you want, but something is disabling America's children and relabeling it and redefining it won't solve the epidemic. They will still be DISABLED. Calling the epidemic something else, therefore eliminating it, doesn't solve an epidemic.
That said, I don't believe the changes to the DSM-5 are going to rule out as many individuals as parents fear. If you read the proposed changes in the link above (and all autism parents, I highly suggest that you do), you will discover that many aspects of the new criteria seem more broad. Indeed, Dr. Catherine Lord of ADOS fame says in the same NY Times article that projections have placed the new criteria as including far more than will be excluded.
Before you pass judgment on the appropriateness of the new criteria based on a single article and study meant to stir up controversy and attention (which it succeeded in doing), I urge you to view the criteria yourself using the link above. Consider it in the context of your child. Indeed, when I look at the new criteria I see that Jack would very easily meet it. Granted, Jack isn't as high-functioning as some kids, and I know that parents of the highest functioning children have the most to lose here. If anything, I believe that the new criteria will help capture children who lay right on the border of ASD/not-ASD, because it allows for consideration of sensory issues, it is not dependent on speech delays, and it recognizes that autism exists as a spectrum.
As always, people are resistant to change. Many people, particularly those with Asperger's, don't like the loss of identity that will come with being lumped in with the general ASD population as a whole. Higher-functioning individuals feel as though being potentially taken off the spectrum will take away their voices for advocacy for their lower-functioning counterparts on the spectrum.
As far as individuals worrying about the loss of services, I don't see how this is any different than what we face right now. School districts have to provide your child what they need to access the curriculum and EI has to provide early intervention for children who quality based on significant developmental delay...nothing more and nothing less. If your child has significant speech and fine motor delays that require ST and OT in order to access the curriculum, it doesn't matter if your child has a diagnosis or not. The same goes for educational support. Now, school systems try to pull these services from our kids anyways, so I think that (unfortunately) it's going to be a fight between parents and government providers no matter what. Parents will ALWAYS have to advocate for their children.
Insurance coverage...that's another story. I'm sure insurers will try to finagle some way to exclude various people from coverage, but that to me is the result of us not having mandates in place to compel insurers to actually treat ALL of the their patients' medical conditions (yes, autism is a medical condition). However, living in the great state of Georgia with crappy autism mandates (which is how our insurer is allowed to provide Jack only 20 visits annually with no appeal options) means that we fight with insurers regardless. The DSM-5 might change that fight, but the fight will still exist.
I honestly don't see how the DSM change is going to strip very many people of their current diagnoses. I believe it will, eventually, make it easier for individuals to obtain coverage and services by lumping them all together under one diagnosis.
My opposition to the criteria change in the DSM is not so much because I don't think the criteria are good (I do) or because I fear Jack will lose his diagnosis (I don't), but because it turns something as important as our children's lives into a matter of semantics. It will affect insurance coverage and services for many during the reshuffle. For adults, they may lose SSI or Medicaid, simply because they no longer have a diagnosis. Does it make them any less disabled? No! So, what do we call these individuals, since we are a society so bound by labels? Once we determine that, what happens to these individuals during the inevitable waiting period it will take before governments and insurers catch up with the new terms? These things don't happen overnight, and insurers and governments will be more than happy to have a reason to spend less on social services.
I also don't like the idea that we can simply change semantics and make an epidemic disappear.
What I really wish is that the APA and framers of the DSM revisions could put efforts and energy into solving the problem. Redefining the problem doesn't solve it. Figure out what is happening to our children! There are so, so many! Figure out why my son won't hug me, or look me in the eye, or point something out to me! This is the one point to this whole debate that makes me want to scream. Please, I beg you, figure out what it is that causes this so that we can prevent it in future children! Put your energies into that, rather than debating what defines our kids as "autistic". This is an epidemic, and simply redefining it won't help the millions who are autistic, regardless of what you choose to label them as being. Instead, stripping them of their services will leave a generation of people unprepared for the demands of adulthood and dependent on social services and the welfare system when they cannot maintain gainful employment.
I'd like to open this up to discussion. Please feel free to comment on the proposed revisions, your thoughts and fears on the issue, and what you'd like to see (or not see) happen to the diagnostic criteria in the future. Don't feel like you need to be a special needs parent to respond. This is an issue that invariably affects our entire country.