Weighing in on Asperger's

With the DSM-V powers-that-be thinking about removing the Asperger's diagnosis from the DSM next edition, it's time for all of us to weigh in our two cents. Here's mine.

The Asperger label is critical to the people who are diagnosed as such. With the label, researchers can more readily target them as a group for study and treatment. Employers see the label and understand the constraints. Therapists see the label and can get right to work on appropriate therapies.

Let's look at it. There are 3 categories of autism that make a difference to me when I treat children:

- True autism with it's social and communication issues.

- PDD-NOS - a form of high functioning autism in which children can get rid of many, many symptoms with multiple therapies to the degree that you can no longer tell that it's autism.

- Asperger's - the other form of high functioning autism with good language skills, the desire to interact with others and a lack of understanding social rules (making interaction very challenging).

The authors of the DSM complain that it is difficult to distinguish Asperger's from autism and that that is the reason that the diagnosis can be removed. I disagree. A child with Asperger's has very good language skills (and in fact can be a chatterbox). Also, he/she lacks social skills in a different way than a child with typical autism does. The child with autism does not typically care to have social interaction and is content in his/her world. The child with Asperger's desperately wants friends but is often clueless on how to get and keep them.

These are easily observed differences. I say leave Asperger's in. And by the way, the same set of arguments are going to apply to PDD-NOS. Leave it in, too.

On another day, I'll talk about the impact of sensory, modulation, ADHD and obsession/compulsion comorbidity.

NAC National Autism Report

I am still coming to grips with the National Autism Center's 2009 report on effective treatments for autism. The group is very influential, but it is a self-interest group made up primarily of behavior analysts. The executive director, Susan M. Wilczynski, Ph.D., BCBA, is a certified behavior analyst (think ABA-style therapies), as are the bulk of the project team that designed the study and reviewed the research articles. I question the impartiality of this study.

Here is my main beef: Articles were only considered for review if they were specifically about autism. From an OT perspective, that leaves out the bulk of our research since the research we do is broad and includes children with many disorders. Our research typically works with specific symptoms rather than patient groups. So when the NAC study looked for effective treatments for motor skills, they did not include the considerable wealth of research performed by OTs and PTs. In fact, the study's outcome did not see the need for OT intervention. Somebody missed something, I think.

And there is a parallel case for considering the area of sensory processing research. There are many, many studies in this area. If you look at my last blog entry, you will see that children with ADHD and anxiety have many of the same symptoms as children with autism. So again, our research covers, as it must, broad groups of children.

Now ABA treatments, on the other hand, were all developed specifically for children with autism, and so the study appears to be biased in favor of this treatment research. But unfortunately other psychology-based treatments such as Floortime and P.L.A.Y. (also developed for children with autism) did not make it through the study review process in as good a standing. Their treatments were found to be "emerging". I hope that this is not yet another case of "convenient" study design.

High Func. Autism vs ADHD vs Anxiety

Research by Hartley & Sikora in a recent issue of Autism Magazine: Can you distinguish high functioning autism from ADHD and from anxiety in older children? Here is a list of the DSM criteria for autism along with the results from a study that tested for each criteria in children with autism, ADHD and anxiety. It turns out that many of the problem areas are shared by the three groups. Check out the list below. (Note: DSM does not allow duel diagnoses such as ASD and ADHD or ASD and anxiety.) ADHD Anxiety Communication Delay/lack of speech Yes Yes Impaired conversational ability No Stereotyped/repetitive language Yes Yes Lack of make-believe play Yes Yes Social Behaviors Non-verbal social behavior No No Failure to develop peer relationships No No Lack of seeking to share Yes Yes Lack of social & emotional reciprocity No No Restricted/repetitive/stereotyped patterns Stereotyped/restrictive patterns of interest No Non-functional routine or ritual No Stereotyped or repetitive motor mannerisms No Preoccupation with parts of objects Yes Yes

Telling the difference: ASD, ADHD and Anxiety

Research by Hartley & Sikora in a recent issue of Autism Magazine: Can you distinguish high functioning autism from ADHD and from anxiety in older children? Here is a list of the DSM criteria for autism along with the results from a study that tested for each criteria in children with autism, ADHD and anxiety. It turns out that many of the problem areas are shared by the three groups. Check out the list below. (Note: DSM does not allow duel diagnosies such as ASD and ADHD or ASD and anxiety.)
ADHD Anxiety Communication Delay/lack of speech Yes Yes Impaired conversational ability No Stereotyped/repetitive language Yes Yes Lack of make-believe play Yes Yes Social Behaviors Non-verbal social behavior No No Failure to develop peer relationships No No Lack of seeking to share Yes Yes Lack of social & emotional reciprocity No No Restricted/repetitive/stereotyped patterns Stereotyped/restrictive patterns of interest No Non-functional routine or ritual No Stereotyped or repetitive motor mannerisms No Preoccupation with parts of objects Yes Yes