Concerns about diagnostic criteria C for ASD and CD

Some concerns with diagnostic criteria C for Autism Spectrum Disorder and Social (Pragmatic) and other Commutation Disorders



Diagnostic criteria for Autism Spectrum Disorder:


A. Persistent deficits in social communication and social
interaction across multiple contexts, as manifested by all of
the following, currently or by history (examples are illustrative,
not exhaustive; see text):

1. Deficits in social-emotional reciprocity, ranging, for
example, from abnormal social approach and failure of
normal back-and-forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or
respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for
social interaction, ranging, for example, from poorly
integrated verbal and nonverbal communication; to
abnormalities in eye contact and body language or deficits
in understanding and use of gestures; to a total lack of
facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding
relationships, ranging, for example, from difficulties
adjusting behavior to suit various social contexts; to
difficulties in sharing imaginative play or in making friends;
to absence of interest in peers.



B. Restricted, repetitive patterns of behavior, interests, or
activities, as manifested by at least two of the following,
currently or by history (examples are illustrative, not
exhaustive; see text):


1. Stereotyped or repetitive motor movements, use of
objects, or speech (e.g., simple motor stereotypies, lining
up toys or flipping objects, echolalia, idiosyncratic
phrases).

2. Insistence on sameness, inflexible adherence to routines,
or ritualized patterns of verbal or nonverbal behavior (e.g.,
extreme distress at small changes, difficulties with
transitions, rigid thinking patterns, greeting rituals, need to
take same route or eat same food every day).

3. Highly restricted, fixated interests that are abnormal in
intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively
circumscribed or perseverative interests).

4. Hyper- or hyporeactivity to sensory input or unusual
interest in sensory aspects of the environment (e.g.,
apparent indifference to pain/temperature, adverse
response to specific sounds or textures, excessive
smelling or touching of objects, visual fascination with
lights or movement).


C. Symptoms must be present in the early developmental period
(but may not become fully manifest until social demands
exceed limited capacities, or may be masked by learned
strategies in later life).

D. Symptoms cause clinically significant impairment in social,
occupational, or other important areas of current functioning.

E. These disturbances are not better explained by intellectual
developmental disorder (intellectual disability) or global
developmental delay. Intellectual developmental disorder and
autism spectrum disorder frequently co-occur; to make
comorbid diagnoses of autism spectrum disorder and
intellectual developmental disorder, social communication
should be below that expected for general developmental
level.



Diagnostic criteria for Social (Pragmatic) and other Communication Disorders:

A. Persistent difficulties in the social use of verbal and nonverbal
communication as manifested by all of the following:


1. Deficits in using communication for social purposes, such
as greeting and sharing information, in a manner that is
appropriate for the social context.

2. Impairment of the ability to change communication to
match context or the needs of the listener, such as
speaking differently in a classroom than on a playground,
talking differently to a child than to an adult, and avoiding
use of overly formal language.

3. Difficulties following rules for conversation and storytelling,
such as taking turns in conversation, rephrasing when
misunderstood, and knowing how to use verbal and
nonverbal signals to regulate interaction.

4. Difficulties understanding what is not explicitly stated (e.g.,
making inferences) and nonliteral or ambiguous meanings
of language (e.g., idioms, humor, metaphors, multiple
meanings that depend on the context for interpretation).


B. The deficits result in functional limitations in effective
communication, social participation, social relationships,
academic achievement, or occupational performance,
individually or in combination.

C. The onset of the symptoms is in the early developmental
period (but deficits may not become fully manifest until social
communication demands exceed limited capacities).

D. The symptoms are not attributable to another medical or
neurological condition or to low abilities in the domains of
word structure and grammar, and are not better explained by
autism spectrum disorder, intellectual developmental disorder
(intellectual disability), global developmental delay, or another
mental disorder.


Concerning about diagnostic C for Autism Spectrum Disorder

C. Symptoms must be present in the early developmental period
(but may not become fully manifest until social demands
exceed limited capacities, or may be masked by learned
strategies in later life).

Although Autism Spectrum Disorder is a neurodevelopmental disorder, but if the symptoms of Autism Spectrum Disorder do not become fully manifested until social demands exceed limited capacity or masked by learned strategies later in life, how are family members and mental health professionals supposed to know about childhood history? What if your family members stopped having good memories about your childhood?

What if you have Autism Spectrum Disorder, but the symptoms did not manifest until older adolescents or adulthood? How are family members and mental health professionals supposed to spot those symptoms behaverly from childhood, if it didn't manifest until later in life?

The problem is that Autism Spectrum Disorder is diagnosed based on behavioral symptoms. The question is if you can have the same brain patterns of Autism Spectrum Disorder without showing obvious symptoms of Autism Spectrum Disorder.

To diagnose Autism Spectrum Disorder that did not manifest until later in life, even if without enough childhood history, is to rule out other neurological disorders that has similar symptoms, and if those neurological disorders are ruled out, then ask a patent what is going on with their mind, the patent without obvious behaviors of Autism Spectrum Disorder will tell you that social rules became too complicated for him or her to follow and that he or she masked diagnostic criteria B for Autism Spectrum Disorder, and that it causes them clinically significant impairment in social,
occupational, or other important areas of current functioning.


Concerned about diagnostic criteria C for Social (Pragmatic) and other Commutation Disorders


C. The onset of the symptoms is in the early developmental
period (but deficits may not become fully manifest until social
communication demands exceed limited capacities).


I have similar concerns about diagnostic criteria C for Social (Pragmatic) Communication Disorder. Although Social (Pragmatic) and other Communication Disorders are neurodevelopmental disorders, what if the symptom of Social (Pragmatic) and other Communication Disorders did not fully manifest until social communication exceed limited capacities? How are family members and mental health professionals supposed to know about childhood history? What if the symptoms of Social (Pragmatic) and other Communication Disorders did not manifest until older adolescents or adulthood? How are family members and mental health professionals supposed to know about childhood history?

To know if a person has Social (Pragmatic) and Other Communication Disorders that did not manifest until later in life, even without enough childhood history, is to rule out neurological disorders that causes similar symptoms, and of those neurological disorders are ruled out, the patent can say that thay meet diagnostic criteria for Social (Pragmatic) or other Communication Disorders that did not manifest until later in life and it causes him or her deficits that result in functional limitations in effective
communication, social participation, social relationships,
academic achievement, or occupational performance,
individually or in combination.

My other concern is that diagnostic criteria for Autism Spectrum Disorder and Social (Pragmatic) and other Communication Disorders has some gender bias. I did a research from DSM-5-TR that most women are four more times less likely to be diagnosed with Autism Spectrum Disorder than men, and that most woman with Autism Spectrum Disorder have fewer obvious symptoms or mask better and tend to socialize better.

Obviously if people don't remember childhood, it might be an issue, but childhood also includes up to perhaps 12 years old, so usually there are some memories, and there is self-report as well which is usually the basis for all those diagnostics.

Basically someone will look at whether there was a change due to circumstances at some point during teenage years or later, then it would rule out childhood, but if it was always like that from memory, then it might include it. Circumstances means some traumatic event, or a big change of environment, some accidents, those type of things that are salient.

Obviously it's not an exact science. It would be nice if it was, but it's not the goal of diagnostic. There are other tests, cognitive tests that are more objective. Perhaps they will find some genetic tests one day, but so far it's a fail. Too many variations.

The gender thing is true, but again a bit irrelevant, since if the person is able to adapt and hide it, they aren't fulfilling the criteria for an impairment. Females that are autistic act more or less like a normal man, so it's not considered an impairment so far. It's only an issue for people who consider autism as an identity and not a disorder. But for psychiatry it's not their concern.

Masking or hiding your symptoms doesn't mean you are not impaired and worries are is that some people can have Autism Spectrum Disorder without showing obvious symptoms and the symptoms might not manifest until later in life.

You can adapt and still be impaired

Medically it has to show, or it's nothing.

1PolarBear wrote:Medically it has to show, or it's nothing.

The symptoms appear in early stages of development, but may not fully manifest until social ruled becomes too complex for the symptoms to become more obvious. It shows, but may not become obvious.

Yes, that's what I said, it shows, but it's not considered pathological until it becomes an actual impairment for social activities.

It's like you could see an increase in blood pressure in someone, but it's not considered a medical condition until a certain point, where people have to check what they eat or take medication.

Basically your concern is that it's too late when the actual medical condition appears, that doctors should start diagnosing high blood pressure.

In reality they do, they take blood pressure, but it won't be called a condition to be diagnosed until there are effects considered a disease, which is what the diagnostic manual is about. So there is a cut off between a personality type if you will, and a disorder relating to such a personality. The first is like blood pressure, the second is an actual condition.

So if you were to take the manual about arterial problems and just reading that, you might have concerns that blood pressure is never taken, that nobody looks at it, but it's not true in reality. It's observed and recorded but not taken care of until it's a real issue, that there are serious symptoms. So the concerns are not warranted based on your data.

Same happens when you go to a dentist. They might say there is some issue at some place, we will wait and see what happens. They don't drill right away, they wait until it's not safe according to their experience.

1PolarBear wrote:Yes, that's what I said, it shows, but it's not considered pathological until it becomes an actual impairment for social activities.

It's like you could see an increase in blood pressure in someone, but it's not considered a medical condition until a certain point, where people have to check what they eat or take medication.

Basically your concern is that it's too late when the actual medical condition appears, that doctors should start diagnosing high blood pressure.

In reality they do, they take blood pressure, but it won't be called a condition to be diagnosed until there are effects considered a disease, which is what the diagnostic manual is about. So there is a cut off between a personality type if you will, and a disorder relating to such a personality. The first is like blood pressure, the second is an actual condition.

So if you were to take the manual about arterial problems and just reading that, you might have concerns that blood pressure is never taken, that nobody looks at it, but it's not true in reality. It's observed and recorded but not taken care of until it's a real issue, that there are serious symptoms. So the concerns are not warranted based on your data.

Same happens when you go to a dentist. They might say there is some issue at some place, we will wait and see what happens. They don't drill right away, they wait until it's not safe according to their experience.

That actually makes sense.

1PolarBear wrote:Yes, that's what I said, it shows, but it's not considered pathological until it becomes an actual impairment for social activities.

It's like you could see an increase in blood pressure in someone, but it's not considered a medical condition until a certain point, where people have to check what they eat or take medication.

Basically your concern is that it's too late when the actual medical condition appears, that doctors should start diagnosing high blood pressure.

In reality they do, they take blood pressure, but it won't be called a condition to be diagnosed until there are effects considered a disease, which is what the diagnostic manual is about. So there is a cut off between a personality type if you will, and a disorder relating to such a personality. The first is like blood pressure, the second is an actual condition.

So if you were to take the manual about arterial problems and just reading that, you might have concerns that blood pressure is never taken, that nobody looks at it, but it's not true in reality. It's observed and recorded but not taken care of until it's a real issue, that there are serious symptoms. So the concerns are not warranted based on your data.

Same happens when you go to a dentist. They might say there is some issue at some place, we will wait and see what happens. They don't drill right away, they wait until it's not safe according to their experience.

The diagnostic criteria for Autism Spectrum Disorder in DSM-5-TR need to be changed, to also include people who developed an understanding of social cues on time, but have deficits in social-emotional reciprocity.


Current diagnostic criteria for Autism Spectrum Disorder in DSM-5-TR:


A. Persistent deficits in social communication and social
interaction across multiple contexts, as manifested by all of
the following, currently or by history (examples are illustrative,
not exhaustive; see text):


1. Deficits in social-emotional reciprocity, ranging, for
example, from abnormal social approach and failure of
normal back-and-forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or
respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for
social interaction, ranging, for example, from poorly
integrated verbal and nonverbal communication; to
abnormalities in eye contact and body language or deficits
in understanding and use of gestures; to a total lack of
facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding
relationships, ranging, for example, from difficulties
adjusting behavior to suit various social contexts; to
difficulties in sharing imaginative play or in making friends;
to absence of interest in peers.




B. Restricted, repetitive patterns of behavior, interests, or
activities, as manifested by at least two of the following,
currently or by history (examples are illustrative, not
exhaustive; see text):


1. Stereotyped or repetitive motor movements, use of
objects, or speech (e.g., simple motor stereotypies, lining
up toys or flipping objects, echolalia, idiosyncratic
phrases).
57

2. Insistence on sameness, inflexible adherence to routines,
or ritualized patterns of verbal or nonverbal behavior (e.g.,
extreme distress at small changes, difficulties with
transitions, rigid thinking patterns, greeting rituals, need to
take same route or eat same food every day).

3. Highly restricted, fixated interests that are abnormal in
intensity or focus (e.g., strong attachment to or
preoccupation with unusual objects, excessively
circumscribed or perseverative interests).

4. Hyper- or hyporeactivity to sensory input or unusual
interest in sensory aspects of the environment (e.g.,
apparent indifference to pain/temperature, adverse
response to specific sounds or textures, excessive
smelling or touching of objects, visual fascination with
lights or movement).



Current diagnostic criteria for Social (Pragmatic) Communication Disorder:



A. Persistent difficulties in the social use of verbal and nonverbal
communication as manifested by all of the following:


1. Deficits in using communication for social purposes, such
as greeting and sharing information, in a manner that is
appropriate for the social context.

2. Impairment of the ability to change communication to
match context or the needs of the listener, such as
speaking differently in a classroom than on a playground,
talking differently to a child than to an adult, and avoiding
use of overly formal language.

3. Difficulties following rules for conversation and storytelling,
such as taking turns in conversation, rephrasing when
misunderstood, and knowing how to use verbal and
nonverbal signals to regulate interaction.

4. Difficulties understanding what is not explicitly stated (e.g.,
making inferences) and nonliteral or ambiguous meanings
of language (e.g., idioms, humor, metaphors, multiple
meanings that depend on the context for interpretation).





We can remove the diagnostic criteria A for Autism Spectrum Disorder and change it into this:


1. Deficits in using communication for social purposes, such
as greeting and sharing information, in a manner that is
appropriate for the social context.

2. Impairment of the ability to change communication to
match context or the needs of the listener, such as
speaking differently in a classroom than on a playground,
talking differently to a child than to an adult, and avoiding
use of overly formal language.

3. Difficulties following rules for conversation and storytelling,
such as taking turns in conversation, rephrasing when
misunderstood, and knowing how to use verbal and
nonverbal signals to regulate interaction.

4. Difficulties understanding what is not explicitly stated (e.g.,
making inferences) and nonliteral or ambiguous meanings
of language (e.g., idioms, humor, metaphors, multiple
meanings that depend on the context for interpretation).





So, this is what the diagnostic criteria for ASD should look like:


(At least two symptoms of persistent deficits in social or other communication, for Autism Spectrum Disorder)



1. Deficits in using communication for social purposes, such
as greeting and sharing information, in a manner that is
appropriate for the social context.

2. Impairment of the ability to change communication to
match context or the needs of the listener, such as
speaking differently in a classroom than on a playground,
talking differently to a child than to an adult, and avoiding
use of overly formal language.

3. Difficulties following rules for conversation and storytelling,
such as taking turns in conversation, rephrasing when
misunderstood, and knowing how to use verbal and
nonverbal signals to regulate interaction.

4. Difficulties understanding what is not explicitly stated (e.g.,
making inferences) and nonliteral or ambiguous meanings
of language (e.g., idioms, humor, metaphors, multiple
meanings that depend on the context for interpretation).


Diagnostic criteria B symptoms for Autism Spectrum Disorder:


(And at least two symptoms of diagnostic criteria B for Autism Spectrum Disorder)


1. Stereotyped or repetitive motor movements, use of
objects, or speech (e.g., simple motor stereotypies, lining
up toys or flipping objects, echolalia, idiosyncratic
phrases).

57

2. Insistence on sameness, inflexible adherence to routines,
or ritualized patterns of verbal or nonverbal behavior (e.g.,
extreme distress at small changes, difficulties with
transitions, rigid thinking patterns, greeting rituals, need to
take same route or eat same food every day).

3. Highly restricted, fixated interests that are abnormal in
intensity or focus (e.g., strong attachment to or
preoccupation with unusual objects, excessively
circumscribed or perseverative interests).

4. Hyper- or hyporeactivity to sensory input or unusual
interest in sensory aspects of the environment (e.g.,
apparent indifference to pain/temperature, adverse
response to specific sounds or textures, excessive
smelling or touching of objects, visual fascination with
lights or movement).

Ore688 wrote:Although Autism Spectrum Disorder is a neurodevelopmental disorder, but if the symptoms of Autism Spectrum Disorder do not become fully manifested until social demands exceed limited capacity or masked by learned strategies later in life, how are family members and mental health professionals supposed to know about childhood history? What if your family members stopped having good memories about your childhood?

What if you have Autism Spectrum Disorder, but the symptoms did not manifest until older adolescents or adulthood? How are family members and mental health professionals supposed to spot those symptoms behaverly from childhood, if it didn't manifest until later in life?

The problem is that Autism Spectrum Disorder is diagnosed based on behavioral symptoms. The question is if you can have the same brain patterns of Autism Spectrum Disorder without showing obvious symptoms of Autism Spectrum Disorder.

To diagnose Autism Spectrum Disorder that did not manifest until later in life, even if without enough childhood history, is to rule out other neurological disorders that has similar symptoms, and if those neurological disorders are ruled out, then ask a patent what is going on with their mind, the patent without obvious behaviors of Autism Spectrum Disorder will tell you that social rules became too complicated for him or her to follow and that he or she masked diagnostic criteria B for Autism Spectrum Disorder, and that it causes them clinically significant impairment in social,
occupational, or other important areas of current functioning.

I have just been through the process of receiving an Autism diagnosis- at age 40. Can I tell you that at no point was the DSM criteria thrown around in the interviews I did with the psychologists assessing me. The process involved them applying multiple quizzes, questionnaires and some practical assessments, which all relate to how I interacted with people and the world around me. There was a specific questionnaire on masking, which is your ability to hide your symptoms, mimic and fit in with the world, or at least you appear to. They could see right through it though, because they know what they're looking for. Women in particular usually score highly on masking, and it's why women are often not diagnosed until they are adults- we've learned to play along with others by copying and mimicking- but frequently burning out as a result.

Looking back, the autism was ALWAYS there. Just no-one ever picked up on it or saw it. Going through the assessment we discussed events during childhood, and I did not have any other family present during the process at all, I did it completely alone. I have some memory issues myself caused by trauma/dissociation, but was still able to explain enough about my childhood experiences, and they had a lot of questions about growing up- I wasn't expected to sit there and give a two hour long lecture on my own development, it was a lot of prompted questions about specific things.

I was 35 when autism was first suggested as a possibility. But looking back now, and after discussing what I know of my history with them, it was clearly obvious I had this as a toddler/small child. So it's not about the symptoms only manifesting as an adult, it's about them finally being recognised.

1PolarBear wrote:The gender thing is true, but again a bit irrelevant, since if the person is able to adapt and hide it, they aren't fulfilling the criteria for an impairment. Females that are autistic act more or less like a normal man, so it's not considered an impairment so far. It's only an issue for people who consider autism as an identity and not a disorder. But for psychiatry it's not their concern.

I don't know that I act like a normal man, I act like a woman who has autism and is largely able to mask it, at great cost- I deal with chronic fatigue and illness because of that. I wouldn't consider autism an identity, but an explanation for a lifetime of "why can't manage to do what everyone else seems to manage in life so easily."