What are the changes pertaining to autism? In DSM-IV, five subtypes were listed under the umbrella of pervasive developmental disorders, or PDD. These were autism, Asperger’s syndrome, pervasive developmental disorder, not otherwise specified (PDD-NOS), Rett syndrome and childhood disintegrative disorder (CDD). The problem was that it was hard to distinguish between them. In DSM-5, autism spectrum disorder (ASD) is a single category. In general practice, Rett syndrome and CDD were rare and thought to be quite different in presentation from ASD, so ASD is an umbrella term for what we previously referred to as autism, Asperger’s and PDD-NOS. A second major change involves the number of criteria individuals need to qualify for a diagnosis. In DSM-IV, there were three categories — social, communication and restrictive or repetitive behaviors. Social and communication have been combined into one category, social communication, and the second category, restrictive and repetitive behaviors, remains the same. What’s important is that the criteria have become more stringent. For example, comparing DSM-5 vs. DSM-IV, one now has to meet all three criteria under social (as opposed to two out of four), and two out of four for repetitive/ restrictive (as opposed to one out of four). There is a concern that many people who have been thought to have autism won’t meet the more stringent criteria. For those who fall just outside of the autism spectrum, there is a separate diagnosis called social communication disorder, although it’s not clear whether these individuals will be able to access the same types of services as those under the ASD diagnosis. Finally, DSM-IV did not allow a diagnosis of attention deficit hyperactivity disorder for those who were in the PDD/autism category, and this led to children with symptoms of both who were being denied ADHD-related services. DSM-5 removes the exclusion criteria, so now one can receive both diagnoses. What do these changes mean for people who have already been diagnosed? Generally, everyone who has already been diagnosed is thought to be “grandfathered” in, meaning already qualifying for the ASD category. The new criteria generally apply only to those who are being evaluated for the first time. However, it’s possible that there may be those who want to reevaluate children who have previously been diagnosed to re- determine eligibility for services or to question previous diagnoses. and PDD-NOS. I also agree with having the ADHD exclusion removed; that will open the door for these individuals to get the right medications and accommodations. There are pros and cons to making the diagnostic criteria more stringent. On the one hand, we don’t want to over-diagnose, but on the other hand, who’s to say that people who meet two out of the three social communication criteria don’t have the same needs as those who meet all three? And these individuals might not get the same services if they don’t meet the new diagnostic criteria. The bottom line is that this is a step on the journey. We are still learning about these disorders, and the criteria will undoubtedly continue to evolve in the next DSM version. Until then, we should work with families to understand the rationale behind these changes and advocate for them to the best of our abilities. Defining the diagnosis is important as a gateway to treatment for insurance purposes, from the public Do you support these revisions? health perspective and For the most part, I do. The single diagnosis makes sense because it has been very hard to distinguish between autism, Asperger’s for researchers. Neelkamal Soares, MD Vital Signs Fall 2013 Vol. 60 9