Saturday, May 13, 2006

DSM-III-R and DSM-IV Autism Criteria

Below, I list the criteria for Autism relative to the DSM-III-R and the DSM-IV.
Comments are welcome and I have dropped the need for a Blogger ID to comment on this post.

DSM-III-R:

Includes at least two items from item A, one from item B, and one from item C:

A. qualitative impairment in reciprocal social interaction (the examples within parentheses are arranged so that those first listed are more likely to apply to younger ormore disabled, and the later ones, to older or less disabled) as manifested by the following:

(1) marked lack of awareness of the existence or feelings of others (for example, treats a person as if that person were a piece of furniture; does not notice another person's distress; apparently has no concept of the need of others for privacy);


(2) no or abnormal seeking of comfort at times of distress (for example, does not come for comfort even when ill, hurt, or tired; seeks comfort in a stereotyped way, for example, says "cheese, cheese, cheese" whenever hurt);

(3) no or impaired imitation (for example, does not wave bye-bye; does not copy parent's domestic activities; mechanical imitation of others' actions out of context);

(4) no or abnormal social play (for example, does not actively participate in simple games; prefers solitary play activities; involves other children in play only as mechanical aids); and

(5) gross impairment in ability to make peer friendships (for example, no interest in making peer friendships; despite interest in making friends, demonstrates lack of understanding of conventions of social interaction, for example, reads phone book to uninterested peer);

B. qualitative impairment in verbal and nonverbal communication and in imaginative activity, (the numbered items are arranged so that those first listed as more likely to apply to younger or more disabled, and the later ones, to older or less disabled) as manifested by the following:

(1) no mode of communication, such as communicative babbling, facial expression, gesture, mime, or spoken language;

(2) markedly abnormal nonverbal communication, as in the use of eye-to-eye gaze, facial expression, body posture, or gestures to initiate or modulate social interaction (for example, does not anticipate being held, stiffens when held, does not look at the person or smile when making a social approach, does not greet parents or visitors, has a fixed stare in social situations);

(3) absence of imaginative activity, such as play-acting of adult roles, fantasy characters, or animals; lack of interest in stories about imaginary events;

(4) marked abnormalities in the production of speech, including volume, pitch, stress, rate, rhythm, and intonation (for example, monotonous tone, question-like melody,or high pitch);

(5) marked abnormalities in the form or content of speech, including stereotyped and repetitive use of speech (for example, immediate echolalia or mechanical repetition of a television commercial); use of "you" when "I" is meant (for example, using "You want cookie?" to mean "I want a cookie"); idiosyncratic use of words or phrases (for example, "Go on green riding" to mean "I want to go on the swing"); or frequent irrelevant remarks (for example, starts talking about train schedules during a conversation about sports); and

(6) marked impairment in the ability to initiate or sustain a conversation with others, despite adequate speech (for example, indulging in lengthy monologues on one subjectregardless of interjections from others);
C. markedly restricted repertoire of activities and interests, as manifested by the following:

(1) stereotyped body movements (for example, handflicking or twisting, spinning, head-banging, complex whole-body movements);

(2) persistent preoccupation with parts of objects (for example, sniffing or smelling objects, repetitive feeling of texture of materials, spinning wheels of toy cars) or attachment to unusual objects (for example, insists on carrying around a piece of string);

(3) marked distress over changes in trivial aspects of environment (for example, when a vase is moved from usual position);
(4) unreasonable insistence on following routines in precise detail (for example, insisting that exactly the same route always be followed when shopping);

(5) markedly restricted range of interests and a preoccupation with one narrow interest (for example, interested only in lining up objects, in amassing facts about meteorology, or in pretending to be a fantasy character);

D. onset during infancy or early childhood;

E. other symptoms that may occur with the syndrome:

(1) sensory disturbances as evidenced by atypical responses to stimuli (for example, touch, sound, light, movement, smell, taste). Responses may include overreaction, indifference, or withdrawal; and

(2) uneven acquisition of skills, and/or difficulty in integrating and generalizing acquired skills; and

F. the pupil's need for instruction and services mustbe supported by at least one documented systematic observation in the pupil's daily routine setting by an appropriate professional and verify the criteria categories in items A to D. In addition, corroboration of developmental or medical information with a developmental history and at least one other assessment procedure that is conducted on a different day must be included. Other documentation should include parent reports, functional skills assessments, adaptive behavior scales, intelligence tests, criterion-referenced instruments, language concepts, developmental checklists, or an autism checklist.


DSM-IV:

A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):

A

(1) qualitative impairment in social interaction, as manifested by at least two of the following:

(a) marked impairment in the use of multiple nonverbal behaviors, such as eye-to- eye gaze, facial expression, body postures, and gestures to regulate social interaction

(b) failure to develop peer relationships appropriate to developmental level

(c) a 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 interest)

(d) lack of social or emotional reciprocity

(2) qualitative impairments in communication, as manifested by at least one of the following:

(a) delay in, or 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)

(b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others

(c) stereotyped and repetitive use of language or idiosyncratic language

(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

(3) restricted, repetitive, and stereotyped patterns of behavior, interests, and activities as manifested by at least one of the following:

(a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus

(b) apparently inflexible adherence to specific, nonfunctional routines or rituals

(c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting or complex whole-body movements)

(d) persistent precoccupation with parts of objects B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.

C. The disturbance is not better accounted for by Rett's disorder or childhood disintegrative disorder.


References

American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Washington, DC: AmericanPsychiatric Association; 1980.

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American PsychiatricAssociation; 1994.

10 Comments:

Blogger r.b. said...

Any life viewed under a microscope is going to look crazy. Many of the criteria are entirely subjective in scope. "You think the way you think you think, therefore, you are crazy in our minds."

I used to give credence to that book before I figured out it was all my parents fault, anyhow...

6:49 PM  
Blogger Interverbal said...

Hi R.B.


Thakd for stopping by:

I don't disagree with what you write. There was a progression across the DSMs which was was ideally, towards more objectivity. I think they acccomplished it to some degree, but only to some degree.

It has ben the source (maybe you know this already) of a major kurfufle over whether autism is actually increasing or whether we have merely broadened the concept of autism (I am simplying of course). So, I posted this so that folks can actually compare the two first hand.

"You think the way you think you think, therefore, you are crazy in our minds."

(laughs) Yeah, I think that is a nice summerization of not just the DSMs, but much of education et al. as well.

Still, I don't think that it is the identification of a difference that is the issue per se. I propose that the problem is the way we look at the differences.

7:25 PM  
Blogger ilse said...

I think it's interesting that my PDD-NOS son would qualify as Autistic under the DSM-IIIR, but as PDD-NOS under the DSM-IV. He'd have become "less severe" overnight! Talk about your miracle cures...

10:36 AM  
Blogger Interverbal said...

Hi isle,

Thanks for stopping by.

Autism (also true for PDD-NOS) are what we define them to be. A lot of people still don't realize that, but they are not in tune with what the field trials for the DSM-IV show. These trials indicated that the the revised PDD-NOS criteria were now broad enough to pick up some kids who were formerly dx'ed with Autistic Disorder as well as kids who would not have been dx'ed in the PDD's at all in the past.

Of course, many of of the autism epidemic theory advocates, would deny that your son could ever have been dx'ed with Autistic Disorder. According to them, these children are just like trainwrecks (their words, not mine) in that they can not possibly be missed or affected by changing criteria (Sadly, that is an honest representation of the positionn of some of them.)

11:14 AM  
Blogger Chris said...

From memory, the change from III-R to IV reduced the number of ways to be autistic from approx. 64,000 to approx. 15,000 (working through all the 3! and 5! combinations). Like most DSM definitions, this is less a description than a means of ensuring that everybody who comes in to the office can be diagnosed as having some named and insurable complaint.

12:36 AM  
Blogger Interverbal said...

Hi Chris,

Lot of permutations!

I think though, that an important change from III-R to IV was the use of slightly more objective criteria. I think this has allowed us better grasp what Autistic Disorder. I would argue that this has helped us, in the long run, to diagnose more persons on the spectrum.

“Like most DSM definitions, this is less a description than a means of ensuring that everybody who comes in to the office can be diagnosed as having some named and insurable complaint.”

Sort of, but it is important to remember that not all the ones who end up being checked for autism (or any difference) end up with a diagnosis.

Personally, I do not mind the looser criteria. I think that this still reflects the concept of ASD and good can be had of this. For example we know that autistics have reported how meaningful it is to be to be around other autistics.

3:48 PM  
Blogger r.b. said...

OH, dear, I meant to say..."You think the way we think you think, therefore, your thinking is crazy because we think it is..."

NO...wait, oh poop, I give up!

I can't believe I wrote that. I wonder how many other posts like that I've put out on the web...

On to my real reason for being here...

Jannalou says you were given ABA as a child, and you might be interesting to talk to about it.

I don't want to bring up any pain. I do want to know more precisely the language difference. I had to show Ben how to talk, and I used the book, but not the behaviorial aspects.

I could say I wish I knew someone who had received NO therapy, but I can't on my blog. It was my nephew, and he is brilliant, and has no label. Lot's of little professors to varying degree's in my family.

6:39 PM  
Blogger Interverbal said...

Hi R.B.,

(laughs) It is all good, I think I got were you were going.

Sorry to disappoint, but I am not autistic (Janna rocks, but I think she might be confusing me for someone else). I have been jokingly called an autistic by others and certainly was a little professor myself and I am learning to be a real professor at this time. Nor was I never in a structured ABA program as a child, except to the extent ABA is used for all kids in school.

I was on the other hand, treated for hyperactivity/daydreaming using a form of quackery known as the Feingold Diet as a child. This was not painful, but merely confusing and sometimes frustrating. The necessity of the diet was explained to me by my allergist (I did and do have bad environmental allergies) as me having “food allergies” that made me feel sick and that would make me hyperactive. Unfortunately, this is a bald faced lie and the allergist would have known that. A major book on the diet explains the rationale; that even if the actual problem was not “allergies” the problem was analogous to allergies, ergo it was okay to explain it as allergies. I think this aptly sums up the ethics of the advocates of that diet, not to mention that by time I found myself on the diet the better designed research had already debunked it.

As to ABA, well, I have used intensive ABA programs in self management on myself as an adult, but that was (obviously) in full consent and had to do with keeping up on a intensive workout schedule for a college club sport.

I am behavior analyst and I am sometimes very critical of practices within the ABA field.

I can recommend Michelle Dawson’s site who is an autistic person (for sure this time) and who might talk about her experiences as an adult (you will have to ask her) this is also a spot where a number of other autistics aggregate. http://www.quicktopic.com/27/H/vJvhV4fDnBgw7

Bravo for the little professors in your family, our world would be a little sadder and poorer without them.

8:59 PM  
Blogger r.b. said...

Looking at the email, she said you were an "ABA STUDENT"...hmmm...there is a difference!

Well, I'm kind of literal...

HaHa...(ahem...)

Glad to know Feingold is a crock. At one time it sounded like an answer. Too many lists.

I wonder how much of what we do for our kids isn't necessary, and they turn out fine in spite of us.

I know so little about behaviorism, other than the man who works with dogs on tv (yeah, I know)...that was all years ago in college. I do wonder if we as humans are all similarly wired animals, and not as complicated as we might think.

1:28 PM  
Blogger Interverbal said...

Hi R.B.,

“I wonder how much of what we do for our kids isn't necessary, and they turn out fine in spite of us.”

There is concept in research, called “regression to the mean”. This is simply a fancy way of saying that persons who different in some way, tend to move towards the center over time. This is something that has to be controlled for in research.

”I know so little about behaviorism, other than the man who works with dogs on tv (yeah, I know)...that was all years ago in college. I do wonder if we as humans are all similarly wired animals, and not as complicated as we might think.”

I am almost done with a post describing behaviorism/behavior analysis I should have it up and running today some time.

1:53 PM  

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