I recently wrote a letter to the editor of a journal which published an editorial by Dr. Francesca Happé, member of the DSM-5 panel working on autistic disorders and who in the editorial offered some reasons for the proposed changes to the criteria for autistic disorders including the elimination of Asperger's Disorder. My letter was not reviewed as the editor politely wrote that it did not meet the priorities of the journal. This is fine with me but I still believe in what I wrote and the letter not being accepted freed me to include it in my website. Below is the letter I submitted to the journal with slight modification.
I am writing this in response to the Dr. Happé's editorial1 in your June, 2011 issue. In her editorial, Dr. Happé, in discussing a paper by Mattila and colleagues2 that argued for retaining the subcategories of autistic spectrum disorders in the DSM-5 and particularly that of Asperger's Disorder, focuses on the reasons for the proposed changes in the DSM-5. I want to address three points of the editorial.
Dr. Happé writes: "It is time to reintegrate Asperger disorder with the rest of the spectrum and to demand the same level of respect and lack of stigma for individuals across the full range of manifestations of ASD." This strikes me as being an unscientific and unsupported opinion. A large part of my practice since 1979 has been devoted to diagnosing, treating and understanding autism (here meaning the whole spectrum). I do not think that autistic individuals who are today diagnosed with Autistic Disorder or Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) are treated with less respect than those diagnosed with AD and I do not think that such opinions should influence the formation of our diagnostic categories.
Dr. Happé goes on to note that when using the existing criteria that "most people with Asperger disorder do meet criteria for autistic disorder...." and she cites a survey of more than 400 clinicians in Australia who "showed that almost half the young people receiving Asperger or PDD-NOS labels in fact met DSM-IV criteria for autistic disorder with poor agreement between label given and criteria met" 3. It has always been my understanding that the DSM-IV diagnosis of Autistic Disorder4 and the diagnoses of Infantile Autism and Autistic Disorder respectively in the DSM-III4 and DSM-III R4 were meant to capture the more impaired autistic individuals who are not hard to distinguish from the more mildly impaired individuals diagnosed with AD. In fact, it is stated in the text of the DSM-III R that Autistic Disorder is also known as Infantile Autism and Kanner Autism. It is surprising to me that many clinicians could diagnose individuals with both Asperger's Disorder and Autistic Disorder. I guess it is the way they interpret the DSM-IV criteria for the two disorders which is, in part, identical for the two disorders. The clinicians included in the survey included child psychiatrists, pediatricians, psychologists, speech and language therapists and "clinicians representing multidisciplinary teams". At the risk of offending any of them, I question their general level of expertise given their lack of perspective on how the two diagnoses evolved.
I am writing this in response to the Dr. Happé's editorial1 in your June, 2011 issue. In her editorial, Dr. Happé, in discussing a paper by Mattila and colleagues2 that argued for retaining the subcategories of autistic spectrum disorders in the DSM-5 and particularly that of Asperger's Disorder, focuses on the reasons for the proposed changes in the DSM-5. I want to address three points of the editorial.
Dr. Happé writes: "It is time to reintegrate Asperger disorder with the rest of the spectrum and to demand the same level of respect and lack of stigma for individuals across the full range of manifestations of ASD." This strikes me as being an unscientific and unsupported opinion. A large part of my practice since 1979 has been devoted to diagnosing, treating and understanding autism (here meaning the whole spectrum). I do not think that autistic individuals who are today diagnosed with Autistic Disorder or Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) are treated with less respect than those diagnosed with AD and I do not think that such opinions should influence the formation of our diagnostic categories.
Dr. Happé goes on to note that when using the existing criteria that "most people with Asperger disorder do meet criteria for autistic disorder...." and she cites a survey of more than 400 clinicians in Australia who "showed that almost half the young people receiving Asperger or PDD-NOS labels in fact met DSM-IV criteria for autistic disorder with poor agreement between label given and criteria met" 3. It has always been my understanding that the DSM-IV diagnosis of Autistic Disorder4 and the diagnoses of Infantile Autism and Autistic Disorder respectively in the DSM-III4 and DSM-III R4 were meant to capture the more impaired autistic individuals who are not hard to distinguish from the more mildly impaired individuals diagnosed with AD. In fact, it is stated in the text of the DSM-III R that Autistic Disorder is also known as Infantile Autism and Kanner Autism. It is surprising to me that many clinicians could diagnose individuals with both Asperger's Disorder and Autistic Disorder. I guess it is the way they interpret the DSM-IV criteria for the two disorders which is, in part, identical for the two disorders. The clinicians included in the survey included child psychiatrists, pediatricians, psychologists, speech and language therapists and "clinicians representing multidisciplinary teams". At the risk of offending any of them, I question their general level of expertise given their lack of perspective on how the two diagnoses evolved.
My last point concerns Dr. Happé's citing the study by Lord and colleagues5 of which Dr. Happé writes: "the same studies suggest that clinicians show good agreement about who falls within versus outside the autism spectrum". The citation does echo the first part of the rationale for the DSM-56 changes to the criteria for autistic disorders that were put on line for comment by the APA. It read: "Differentiation of autism spectrum disorder from typical development and other "nonspectrum" disorders is done reliably and with validity". I don't know the basis for this. If it is meant that some tool for diagnosing these disorders such as a structured interview or rating scale has such sensitivity, specificity and precision, I don't think that this has been shown. My criteria for Asperger's Disorder derives from my interpretation of the DSMs in the light of the mass of literature, including scholarly articles and first hand accounts of individuals so diagnosed, that have accrued over the years since 1994 and attest to the value of having placed Asperger's Disorder in the DSM-IV, flawed criteria or not.
References
1Happé M. Editorial: Criteria, Categories, and Continua: Autism and Related Disorders in DSM-5. J Am Acad Child Adolesc Psychiatry. 2011;50:540-542.
2Mattila ML, Kielman M, Linna SL et al. Autism spectrum disorders according to DSM-IV criteria; an epidemiological study. J Am Acad Child Adolesc Psychiatry. 2011;50:583-592.
3Williams K et al. Diagnostic labeling of autistic spectrum disorders in NSW. J. Paediatr Child Health, 2008; 44:108-113.
4American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd., 3rd. revised and 4th. editions respectively. Washington, DC: American Psychiatric Association, 1980, 1987 and 1994.
5Lord C, Petkova E. Hus V et al. A multi-site study of the clinical diagnosis of different autism spectrum disorders. Unpublished manuscript, 2011. {This paper was published in the Archives of General Psychiatry, 2012; 69: 306-313 after I submitted my letter.}
6American Psychiatric Association. Proposed draft revisions to DSM disorders and criteria. www.dsm5.org/proposedrevisions.
References
1Happé M. Editorial: Criteria, Categories, and Continua: Autism and Related Disorders in DSM-5. J Am Acad Child Adolesc Psychiatry. 2011;50:540-542.
2Mattila ML, Kielman M, Linna SL et al. Autism spectrum disorders according to DSM-IV criteria; an epidemiological study. J Am Acad Child Adolesc Psychiatry. 2011;50:583-592.
3Williams K et al. Diagnostic labeling of autistic spectrum disorders in NSW. J. Paediatr Child Health, 2008; 44:108-113.
4American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd., 3rd. revised and 4th. editions respectively. Washington, DC: American Psychiatric Association, 1980, 1987 and 1994.
5Lord C, Petkova E. Hus V et al. A multi-site study of the clinical diagnosis of different autism spectrum disorders. Unpublished manuscript, 2011. {This paper was published in the Archives of General Psychiatry, 2012; 69: 306-313 after I submitted my letter.}
6American Psychiatric Association. Proposed draft revisions to DSM disorders and criteria. www.dsm5.org/proposedrevisions.