There was a time in the not-so-distant past when children with autism were given one of four diagnoses based on criteria established some 20 years ago: autism, Asperger's, childhood disintegrative disorder, or pervasive development disorder not otherwise specified (PDD-NOS). But today, that's no longer the case. "We've learned a lot about autism over the last couple of decades, including the fact that these disorders are all a form of autism," says Anna Maria Wilms Floet, M.D., a behavioral developmental pediatrician at the Kennedy Krieger Institute's Center for Autism and Related Disorders in Baltimore, Md.
Doctors also now recognize that symptoms of autism fall on a spectrum, varying by severity and type and affecting kids in distinct ways. "Two kids with autism spectrum disorder (ASD) can behave very differently," says Dr. Wilms Floet.
To help arrive at a diagnosis, doctors refer to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). In order to make detection easier and facilitate earlier intervention, the fifth edition of the DSM (DSM-5), published in 2013, no longer categorizes autism by type. Instead, the new manual outlines two criteria that must be present for an autism diagnosis. They include:
- Deficits in social skills and social communication: This includes lack of eye contact, lack of empathy, and difficulties using and understanding gestures, body language, facial expressions and tone of voice, and difficulties maintaining relationships such as sharing in imaginative play and an absence of interest in peers.
- Unusual patterns of behaviors and interests: This includes repetitive behaviors such as rocking, hand flapping or lining up toys or other objects in a set pattern; an intense fixation on a particular interest, such as airplanes; repetitive speech; unusual reactions to sounds, smells, textures, and visual stimuli; and a high, inflexible need for established routines.
During diagnosis, physicians also note whether a child shows signs of specific co-current conditions, such as intellectual impairment, language impairment, a genetic disorder, or a mental or behavioral disorder like ADHD. "Once we determine that a child has autism, we look at the severity of the symptoms using a three-level scale from the DSM-5," says Dr. Wilms Floet. The levels, listed below, take into consideration how much support a child will need in order to function at home, at school and in society and reflects difficulties in social communication and restricted, repetitive behaviors.
- Requiring Support (Level 1): Social Communication - This child speaks in full sentences, but struggles to engage in back-and-forth conversations. He may make odd, unsuccessful attempts to connect with his peers. Restricted, Repetitive Behaviors - The child's repetitive behavior causes interference in one or more contexts. For example, he may have difficulty shifting between tasks which interferes with his ability to follow a school schedule.
- Substantial support (Level 2): A child may speak in simple sentences or limit his interactions to a specific interest. Restricted, Repetitive Behaviors - This child's repetitive behaviors are obvious to the casual observer and cause difficulties in multiple settings. For example the child may talk excessively about a specific topic which creates social difficulties with school peers and family members.
- Very substantial support (Level 3): "This is a child with severe deficits in verbal and nonverbal social communication skills or extreme behaviors," says Dr. Wilms Floet. Restricted, Repetitive Behaviors - This child's repetitive behaviors produce marked impairment in many contexts. For example the child spends the majority of his time engaged in stereotyped behaviors to the exclusion of interacting with others.
"Because the level of disability and combination of symptoms varies so much by child, it's hoped that these new criteria will help more children get properly diagnosed at earlier ages so they can start treatment sooner," she says. Children previously diagnosed with a specific type of autism, such as Asperger's, still meet the DSM-5 criteria for an autism diagnosis and are still eligible for support services.
As always, you should see your child's doctor any time you're concerned about your child's health and development. He or she will be able to help you and your child assess the best course of action and find the support and education you need.
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