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antimuda
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20 Jan 2012, 10:39 am

As many on this forum are aware the committee revising the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) scheduled for publication in May 2013 has recommended the Asperger's be subsumed by Autistic Disorder (Autism Spectrum Disorder). {link removed}

As today's NY Times article highlights {link removed}

The same committee is also recommending the change to the criterion for Autism Spectrum Disorder. {link removed}

The contradiction I believe arises from criterion C of the new standard
"C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)"

As the basis for the elimination of Asperger's the same committee cites, "Early language details are hard to establish in retrospect, especially for older children and adults". If establishing the usage of language is prohibitively difficult then how can the nuanced social behaviors be retroactively determined?

In addition if we look at criterion D of the new standard
"D. Symptoms together limit and impair everyday functioning."
The original Aperger's requirement was for "significant impairment" and the DSM-IV ASD was for "qualitative impairment". However the standard goes further and adds the term limit. For the new diagnose to be applied there would not only have to be impairment but there would also have to be a limit (the final, utmost, or furthest boundary or point as to extent, amount, continuance, procedure, etc.) on the persons every day functioning. The contradiction arises from the fact that if the function of an individual is to the comparable to a standard individual even if significant impairments and difficulties are overcome a diagnosis would not be possible. In addition if an individual were to work through therapy or other means to overcome their impairments to obtain standard level functioning they would lose the diagnosis and potential subsidies/ accommodations though the underlying impairments may remain. This same logic would argue that an individual with an amputated leg who through the use of a prosthetic had obtained a normal everyday functioning would no longer be able to be diagnosed as an amputee.

Essentially in its recommendation to remove Asperger's from the DSM, the committee argues that the standard is not applicable in clinical settings and that the condition is indistinguishable from High Functional Autism (a term not defined by the DSM) and therefore should be covered under the umbrella of Autism Spectrum disorders. The clinical data in support of this position is at best inconclusive however it is the committees charge to act as the universal lexicographer. Yet in the establishment of the new ASD standard, the committee introduces a similar retroactive problem cited in the Asperger's case and creates an economic moral hazard against any therapy which would increase limits.



Mysty
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20 Jan 2012, 11:16 am

I don't agree with your interpretations.

Saying "C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)" doesn't mean they have to be able to retrospectively have all the details of what was going on in childhood. Mostly (in my opinion) it means the diagnosis wouldn't apply if you look back and clearly see an absence of symptoms. It doesn't mean they can't diagnose it where there's a lack of information or limited information.

Also, saying "D. Symptoms together limit and impair everyday functioning" is NOT saying there has to be any kind of a limit. Verb versus noun, two different words. I would say the verb "limit" indicates there's a limitation, not a limit. Limitation in the sense of "a disadvantage or weak point that makes someone or something less effective". No implication of any sort of limit.


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antimuda
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20 Jan 2012, 11:56 am

Mysty-
C- The same committee in its recommendation for the removal of Asperger's from the DSM puts forth the argument that
" Early language details are hard to establish in retrospect, especially for older children and adults; average age of first diagnosis is late (7 years according to Mandell et al. 2005; 11yrs, Howlin & Asgharian, 1999)."

This was in response to the DSM-IV Asperger requirement that
D. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years).

The new ASD requirement states that, "Symptoms must be present in early childhood". The symptons are defined as

Quote:
A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following:
1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction,
2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures.
3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people
B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:
1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).
2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes).
3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).


Therefore to meet the criterion of C, the symptoms must have occurred early in childhood. Clearly there are more criteria that must be met than in the Asperger's standard and many of the items are highly subject to context and interpretation. Since the committee believe that language is difficult to establish retroactively it would therefore lead to the conclusion that establishing these new criteria would be as difficult if not more. I am not a clinician and do not know the burden of proof that would be applied but I can look at the committees own remarks.

In regard to D
Impair- to make or cause to become worse; diminish in ability, value, excellence, etc.;
Limit - to fix or assign definitely or specifically.
- something that bounds, restrains, or confines
-: the utmost extent

I don't understand why you are mentioning the word limitation which does not appear in either the DSM-IV or DSM-V standard. If your definition of limit was applied it would be redundant with the term impair, thus there would be no need for it to be included. Both words are deliberately included by the author as the original definition only included the term impair[ment]. Thus the author wants to emphasis that the symptoms must specificity defines the utmost extent and diminish every day functioning



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20 Jan 2012, 1:25 pm

I didn't define limit.

You say the word limitation doesn't appear. Neither does the word limit as a noun, as you used it.


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antimuda
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20 Jan 2012, 1:52 pm

Mysty-
I did not intend to define the part of speech that was being used. As you can see below the meaning of the term is consistent for both a noun and verb

Quote:
Limit
noun
1.
the final, utmost, or furthest boundary or point as to extent,amount, continuance, procedure, etc.: the limit of hisexperience; the limit of vision.
2.
a boundary or bound, as of a country, area, or district.
3.
Mathematics .
a.
a number such that the value of a given functionremains arbitrarily close to this number when theindependent variable is sufficiently close to a specified point or is sufficiently large. The limit of 1/ x is zero as x approaches infinity; the limit of ( x − 1) 2 is zero as x approaches 1.
b.
a number such that the absolute value of the differencebetween terms of a given sequence and the numberapproaches zero as the index of the terms increases toinfinity.
c.
one of two numbers affixed to the integration symbol fora definite integral, indicating the interval or region overwhich the integration is taking place and substituted ina primitive, if one exists, to evaluate the integral.
4.
limits, the premises or region enclosed within boundaries:We found them on school limits after hours.
5.
Games . the maximum sum by which a bet may be raised atany one time.
6.
the limit, Informal . something or someone thatexasperates, delights, etc., to an extreme degree: You havemade errors before, but this is the limit.
verb (used with object)
7.
to restrict by or as if by establishing limits (usually followedby to ): Please limit answers to 25 words.
8.
to confine or keep within limits: to limit expenditures.
9.
Law . to fix or assign definitely or specifically.


The reason I included a definition parenthetically in the original posting was to highlight the inclusion of a new word in the standard that dramatically changed the meaning. To meet the new diagnostic criteria the symptoms need not only impair but also confine an individuals daily functioning.

I also must have misunderstood you when you stated,
Quote:
I would say the verb "limit" indicates there's a limitation, not a limit. Limitation in the sense of "a disadvantage or weak point that makes someone or something less effective".
If not to define the term, what did you mean?



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20 Jan 2012, 4:17 pm

Okay, I thought you meant the noun limit.

Still, I'd say that's not a full definition of the verb limit, but talking about it's meaning relates to those of related nouns.

Again, the use of the verb "limit" in the diagnostic criteria does not mean that those who meet the diagnostic criteria have limits. Even though the two words look and sound the same and are related in meaning, that still doesn't follow.

And the meaning of a noun and verb are never the same. The meanings may be related, but not the same. They can't have the same meaning, because they do different things in speech.

And if you don't get it, well, I really have no more to add. I just hope you are open to the idea that maybe the seeming contradictions come out of your limited understanding, instead of actually being there in the diagnostic criteria.


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freewaydog
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20 Jan 2012, 6:54 pm

Well, read this article & you tell me what it means.


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20 Jan 2012, 8:12 pm

Well, it's always better to read the study itself rather than a newspaper article about a study because newspapers are usual selective about which information they choose to present, they often present the information inaccurately and without essential context and they almost always sensationalise results, sometimes to the point that they completely misrepresent the study.

Going by the newspaper article I see a number of red flags. It was co-authored by someone who they say resigned from the original DSM review team, which may mean that there is a bit of academic point scoring and grudge settling going on here. The study is based on information gleaned from a study undertaken in 1993, so the original data is almost 20 years old. I'd have more confidence in a more comprehensive and wider review of more recent data from a number of studies. And finally this is only one study which contradicts the findings of other, more numerous studies.

I'm not convinced.



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20 Jan 2012, 9:05 pm

& here is more information:

http://www.nytimes.com/interactive/2012 ... utism.html


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21 Jan 2012, 2:59 am

freewaydog wrote:


A graph, from the same newspaper about the same, more than likely dodgy, study....



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21 Jan 2012, 7:30 am

Well, it will all come down to this. Asperger's will be removed from the book. Therefore, it will not exist. If something does not exist, there can be no supports for it, right?


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antimuda
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21 Jan 2012, 9:40 am

Mysty-
The definition of limit I posted was the complete listing from dictionaryDOTcom. I would not have posted my contentions on this forum if I was not open to discussing the interpretation and understanding of the DSM. Unfortunately you have failed to address the merits of my position and have instead presented a semantical argument

freewaydog & Marcia
I have read both the NY Times article and the actual committee findings. I had originally posted the link to the documents but had to remove them due to the policies of this message board. It is my belief that the Times article does not go far enough when it says

Quote:
Under the current criteria, a person can qualify for the diagnosis by exhibiting 6 or more of 12 behaviors; under the proposed definition, the person would have to exhibit 3 deficits in social interaction and communication and at least 2 repetitive behaviors, a much narrower menu.


The article fails to address new criterion C and D. Criteria C, as the DSM Committee notes in its finding on Asperger's, is prohibitively difficult to apply for the diagnosis of older children and adults. Criterion D in my opinion presents the larger challenge to the Asperger's community as it requires symptoms to both "limit and impair everyday functioning". The term limit is critically important and will disqualify more than those disqualified on the revision in the social deficit and repetitive behavior disorders. It is no longer sufficient to merely demonstrate an impairment but the symptoms must limit every day functioning. If through considerable effort, an individual is able to overcome their symptoms to lead a 'normal' functioning life, they fail to meet the diagnostic criteria. For those with governmental subsidies, this in fact creates an economic moral hazard.

freewaydog
There is support for a large number of things that do not exist (Santa Clause for instance) Changing or removing the label does not have an effect on the underlying condition. The symptoms captured by the DSM-IV Asperger's definition will continue to manifest.



Last edited by antimuda on 21 Jan 2012, 1:55 pm, edited 1 time in total.

freewaydog
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21 Jan 2012, 9:47 am

antimuda wrote:
freewaydog
There is support for a large number of things that do not exist (Santa Clause for instance) that have a large amount of support. Changing or removing the label does not have an effect on the underlying condition. The symptoms captured by the DSM-IV Asperger's definition will continue to manifest.


I certainly hope you are right! I think ppl do not believe in this diagnosis as it is! I think they are trying to squelch the supports given! Is there a workaround? A compromise? I cannot fight this! It is way too big for me!


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21 Jan 2012, 2:44 pm

freewaydog wrote:
Well, it will all come down to this. Asperger's will be removed from the book. Therefore, it will not exist. If something does not exist, there can be no supports for it, right?


Homosexuals seem to find support, despite not having a disorder. There's different types of support.

Also, Asperger's is just a label. Getting rid of that label (as an official disorder, that is) doesn't mean people with that label don't have a disorder. They aren't getting rid of Asperger's, they are combining it with Autism.


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antimuda
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21 Jan 2012, 5:13 pm

freewaydog-
In recommending that Asperger's be subsumed by ASD, the committee found that "Asperger disorder is not substantially different from other forms of ‘high functioning’ autism (HFA)" and that the condition does not require different treatments or result in different responses to the same treatments. These are the findings of the committee are are open to debate.

A better question is to the value of the label. There are self selecting support groups for people with particular physical attributes (race, height, intelligence etc) and behaviors (gambling, coin collecting, alcoholism etc). Clearly an Asperger's group would span both groupings yet a formal diagnosis would not be required. However the value of the label does extend beyond a support group of 'similar minded individuals' (pun intended) to government programs. In many countries (including the US) Asperger's would qualify in certain circumstances for disability payments. Yet I find it difficult to believe that if an individuals impairment is strong enough to require government assistance that the new ASD criteria could not be met. The problem is for government programs that extend into education. A diagnosis of Asperger's allows a student 'reasonable accommodations' for all tests including University Admission testing (SAT ACT etc). These accommodation most often are for additional time or that the test be conducted in a segregated room (for noise or lightening sensitivity). My concern is under the new standard would these students whose disability is not severe enough to "limit" their abilities but does impair their ability to compete with their peers will be denied simple accommodations.

Mysty-
I appreciate you reference to homosexuality as it was included in the DSM-III. However there is a significant difference between clinical classification homosexuality and Asperger's. There are many individuals with Asperger's that are able to access financial government subsidies and other accommodations (particular in education) because of their diagnosis. Without the 'label' these services would be inaccessible. Besides equal treatment under the laws (for such things as marriage and military service), I am unaware of the homosexual community requiring any additional accommodation or subsidies.