Autism at 70 — Redrawing the Boundaries

Trent Center for Bioethics, Humanities, and History of Medicine, Duke University School of Medicine, Durham, NC, USA.
New England Journal of Medicine (Impact Factor: 55.87). 09/2013; 369(12):1089-91. DOI: 10.1056/NEJMp1306380
Source: PubMed


Though the DSM-5 definition of autism refers to it as a spectrum, in important ways it represents an effort to define the syndrome more sharply. It thus reflects one of the central themes in the history of autism: a debate over where to set its boundaries. This year's revision of the diagnostic criteria for autism is among the most contentious of any in the new Diagnostic and Statistical Manual of Mental Disorders (the fifth edition, or DSM-5), provoking widespread fears among parents and advocacy groups that children who have received a diagnosis of autism will lose their eligibility for services. Coincidentally, this year also marks the 70th anniversary of psychiatrist Leo Kanner's first clinical description of autism in 1943.(1) Though the DSM-5 definition explicitly refers to autism as a spectrum, in important ways it represents an effort to define the syndrome more sharply. In this respect, ...

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    • "There is also less flexibility in terms of the symptoms required to meet the diagnostic threshold. Thus the new criteria create a more streamlined framework for clinicians by reducing the number of possible symptom combinations at their disposal (Baker 2013). As summarized by a member of the work group, the rationale for the changes can be described thusly: " Our aim is to acknowledge the widespread consensus that Asperger syndrome is part of the autism spectrum, to clean up a currently hard-to-implement and contradictory diagnostic schema, and to do away with distinctions that are made idiosyncratically and unreliably " (Happe 2011). "
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    ABSTRACT: A central mechanism by which medicalization occurs is through domain expansion, wherein an existing diagnostic definition widens to include cases beyond its original scope. This has been especially commonplace with respect to mental illness diagnoses. In contrast, there are few clear instances of domain contraction. The controversy surrounding the revisions to autism in advance of the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is thus of considerable importance. Many autism advocates feared the new definition of autism would exclude a significant number of individuals who are already diagnosed. We examine lay claims making to this perceived instance of domain contraction through a content analysis of online reader comments to a high-profile New York Times article reporting on the DSM-5 autism criteria. Our analysis points to an amorphous group of social stakeholders who express a variety of concerns about unabated medicalization. We also identify the stance of diagnostic domain defense, which is an oppositional response by laypeople with a personal connection to a diagnosis to a real or perceived challenge to the definitional boundaries of that diagnosis. Our analysis explicates the dimensions of diagnostic domain defense, which include its grounding in experiential certainty and anguish, and the accrual and deployment of diagnostic resources. We make a case for the utility of this concept for theorizing the relationship between lay claims making, diagnoses, and medicalization. We also make a case for the use of online reader comments as a way to unobtrusively study lay claims making related to pressing social problems in the Internet era.
    Preview · Article · Mar 2015 · Social Problems
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    • "Research in Autism Spectrum Disorders interaction, and restricted, repetitive patterns of behaviors, interest, or activities, and ADHD manifests the inability to marshal and sustain attention and modulate activity level (Rappley, 2005; Baker, 2013; Lai, Lombardo et al., 2013; Volkow & Swanson, 2013). Previous studies have reported that 20–50% of patients with ADHD exhibit autistic traits or even meet the criteria of ASD, and this comorbidity interferes with their psychopathology, and interpersonal, school, family, and cognitive domains (Rommelse, Franke et al., 2010; Kotte, Joshi et al., 2013). "
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    ABSTRACT: Attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are both frequently comorbid with other psychiatric disorders, but the comorbid effect of ASD and ADHD relative to the comorbid risk of other psychiatric disorders is still unknown. Using the Taiwan National Health Insurance Research Database, 725 patients with ASD-alone, 5694 with ADHD-alone, 466 with ASD + ADHD, and 27,540 (1:4) age-/gender-matched controls were enrolled in our study. The risk of psychiatric comorbidities was investigated. The ADHD + ASD group had the greatest risk of developing schizophrenia (hazard ratio [HR]: 95.89; HR: 13.73; HR: 174.61), bipolar disorder (HR: 74.93; HR: 19.42; HR: 36.71), depressive disorder (HR: 17.66; HR: 12.29; HR: 9.05), anxiety disorder (HR: 49.49; HR: 50.92; HR: 14.12), disruptive behavior disorder (HR: 113.89; HR: 93.87; HR: 26.50), and tic disorder (HR: 8.95; HR: 7.46; HR: 4.87) compared to the ADHD-alone, ASD-alone, and control groups. Patients with ADHD + ASD were associated with the greatest risk of having comorbid bipolar disorder, depressive disorder, anxiety disorder, disruptive behavior disorder, and tic disorder. The diagnoses of ASD and ADHD preceded the diagnoses of other psychiatric comorbidities. A comprehensive interview scrutinizing the psychiatric comorbidities would be suggested when encountering and following patients with both ASD and ADHD in clinical practice.
    Full-text · Article · Nov 2014 · Research in Autism Spectrum Disorders
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    ABSTRACT: Abstract The papers on early identification and early intervention for autism spectrum disorders (ASD) in this scientific forum (published in volume 16(1) International Journal of Speech-Language Pathology) raise many important points, including describing the substantial progress made to date as well as analyses of current gaps and weaknesses in the existing evidence base. It is humbling to see the collective expertise of the distinguished authors contributing to this scientific forum including interdisciplinary perspectives and it is not surprising that there is ongoing debate on this important topic. In addition to discussing the points raised by these authors, this paper considers the implications of the new diagnostic criteria for ASD and for social communication disorder (SCD) in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) in the US. Differential diagnosis of ASD and SCD will be paramount in testing early intervention for ASD and the expertise of speech-language pathologists in identifying SCD in infants and toddlers will be a central feature of discovery for both early identification and for early intervention in the decades to come. Finally, a biomedical example on testing early intervention on a spectrum disorder, derived from diabetes, is presented to illustrate both the promise and the pitfalls in testing interventions in the absence of well-validated assessment and intervention paradigms.
    Full-text · Article · Feb 2014 · International Journal of Speech-Language Pathology
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