The autism spectrum disorder ‘epidemic’: Need for biopsychosocial formulation

While a discussion of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) changes in relation to ‘autism spectrum disorder’ (ASD) is timely, the Commentary by Basu and Parry (2013) focuses on apparent overdiagnoses prior to DSM-5, with an increased prevalence from two to five per 10,000 in 1960 to 50 to 114 per 10,000 in recent years. This diagnostic ‘upcoding’ is postulated as being due to educational and welfare resource allocation needs, particularly in the Asperger’s disorder category. The removal of Asperger’s syndrome from the DSM-5 and its replacement by more ‘strict’ criteria is predicted by the authors to correct a ‘growing epidemic of ASDs’, with a ‘deleterious effect on a child’s psychosocial development via self, family, teacher, peer and others’ reduced expectations’, as well as denial of trauma, maltreatment and insecure attachment.

While concerns about over- and misdiagnosis are understandable, there are ‘con’ sides to the argument. First, the ‘strict’ nature of the new criteria may disadvantage younger children whose symptomatic phenomena may still be emerging. Second, the overlap with language disorder is downplayed in the DSM-5, possibly leading to diminished funding for speech pathologists in this population – one of the more useful treatments for younger children. The DSM-5 appears to have replaced Asperger’s disorder with ‘Social (Pragmatic) Communication Disorder’, which may not achieve remedial funding. In Australia, these are also important issues for the new National Disability Scheme.

The authors are also critical of the ‘neo-Kraepelinian paradigm that underpins the DSM since DSM-III’. The authors suggest a ‘biopsychosocial’ formulation. However, they fail to point out that a concern in this regard is the removal of the Multi-Axial Assessment from the DSM-5. As well as their importance for teaching, these axes allowed the application of the bio-psycho-social model, including intellectual social and medical issues, rather than unwieldy V-codes, which are listed at the end of the DSM-5 and describe a heterogeneous group of social problems.

A useful discussion of DSM-5 autism spectrum changes was reviewed in Clinical Psychiatry News (Kilgore, 2013) of a study by Shulman et al. from the Annual Meeting of the Pediatric Academic Societies (PAS). The investigators examined 237 children diagnosed with ASD by the age of 3 years between 2003 and 2010, utilizing DSM-IV criteria and the Childhood Autism Rating Scale (CARS) scores. They also used an algorithm to map these data on to DSM-5 criteria. They found that only 35% of children diagnosed with ASD by age 3 years at their early intervention program met DSM-5 criteria. These children who retained the diagnosis had high CARS scores (more severe social impairment) and a trend to lower IQ. The investigators suggest that very young, still developing children may be disadvantaged by not meeting the DSM-5’s more strict social communication definitions, such as ‘difficulty making friends’ – particularly the less severe children, who might benefit most from early intervention.

Thus, while potentially saving some of the health and disability dollars in Australia, the more narrow definition could disadvantage younger children and also older children previously diagnosed with Asperger’s disorder. There is no guarantee that the generic ‘Attachment Deficit’ formulation is more beneficial for older children with social deficits, who withdraw into computer game ‘addiction’, than a targeted program. Discussion of these issues is useful at this point, but it remains to be seen who gains and who loses from the changes. One suspects that the educational and remedial funding of disabled children might be the loser.

See Viewpoint by Basu and Parry, 2013, 47(12): 1116–1118.