brief report: an exploratory study comparing diagnostic outcomes for autism spectrum disorders under...
TRANSCRIPT
BRIEF REPORT
Brief Report: An Exploratory Study Comparing DiagnosticOutcomes for Autism Spectrum Disorders Under DSM-IV-TRwith the Proposed DSM-5 Revision
Vicki Gibbs • Fiona Aldridge • Felicity Chandler •
Ellen Witzlsperger • Karen Smith
Published online: 8 June 2012
� Springer Science+Business Media, LLC 2012
Abstract The proposed revision for Autism spectrum
disorders (ASDs) in the Diagnostic and Statistical Manual
of Mental Disorders—Fifth Edition (DSM-5) represents a
shift from the Diagnostic and Statistical Manual of Mental
Disorders—Fourth Edition, Text Revision (DSM-IV-TR).
As the proposed DSM-5 criteria require a higher minimum
number of symptoms to be present compared to DSM-IV-
TR, there have been some concerns about the impact that
this will have on diagnostic outcomes. Therefore, the cur-
rent study aimed to compare diagnostic outcomes using
both DSM-IV-TR and DSM-5 criteria for 132 children. Of
the 111 participants who received an ASD diagnosis under
DSM-IV-TR, 26 did not meet DSM-5 criteria. The majority
of these had received a DSM-IV-TR PDD-NOS diagnosis.
Implications of the results and the proposed DSM-5
changes to the ASD criteria are discussed.
Keywords Autism spectrum disorder � Asperger’s
Disorder � Autistic Disorder � PDD-NOS � Assessment �Diagnosis � DSM-IV-TR � DSM-5 �Social Communication Disorder
Introduction
The proposed revision for Autism spectrum disorders
(ASD) in the Diagnostic and Statistical Manual of Mental
Disorders—Fifth Edition (DSM-5, accessible at www.DS
M-5.org) has created some controversy in recent times,
most notably in relation to the possibility that some indi-
viduals who would currently meet criteria under the
Diagnostic and Statistical Manual of Mental Disorders—
Fourth Edition, Text Revision (DSM-IV-TR; American
Psychiatric Association 2000) will no longer meet criteria
under the proposed DSM-5.
DSM-IV-TR places ASDs under the category of per-
vasive developmental disorders (PDDs), which also
includes two non-ASD PDDs i.e. Rett’s syndrome and
childhood disintegrative disorder. DSM-IV-TR outlines
twelve possible ‘‘symptoms’’ of ASD within three areas of
impairment, i.e. social interaction, communication and
restricted and repetitive interests, activities and behaviors
(RRBs). There are three possible ASD diagnoses in DSM-
IV-TR i.e. Autistic Disorder, Asperger’s Disorder and
Pervasive Developmental Disorder-Not Otherwise Speci-
fied (including Atypical Autism; PDD-NOS). These three
categories are set out in a hierarchical fashion in DSM-IV-
TR whereby Autistic Disorder requires the highest mini-
mum symptom set (i.e. at least six characteristics in total
across all three areas with at least two from the social
interaction area, one from communication area, and one
from RRBs and abnormality apparent by age 3 years). A
diagnosis of Asperger’s Disorder can be considered once
Autistic Disorder is ruled out, requiring at least two social
interaction characteristics and at least one characteristic
from RRBs. There can be no cognitive or adaptive delay
and there must be evidence of functional impairment. If an
individual does not meet criteria for Autistic Disorder or
V. Gibbs (&) � F. Aldridge � F. Chandler � E. Witzlsperger �K. Smith
Diagnostic Assessment Service, Autism Spectrum Australia
(Aspect), PO BOX 361, Forestville, NSW 2087, Australia
e-mail: [email protected]
F. Aldridge
e-mail: [email protected]
F. Chandler
e-mail: [email protected]
E. Witzlsperger
e-mail: [email protected]
K. Smith
e-mail: [email protected]
123
J Autism Dev Disord (2012) 42:1750–1756
DOI 10.1007/s10803-012-1560-6
Asperger’s Disorder, then PDD-NOS can be considered.
This is the least stringent of the ASDs outlined in DSM-IV-
TR and requires evidence of severe social impairment
accompanied by either communication impairment or
RRBs. There is no specific minimum number of symptoms
outlined.
The proposed revision for ASDs in DSM-5 consists of a
single category, i.e. Autism spectrum disorder. The ratio-
nale for the removal of the three category system outlined
on the DSM-5 website by the DSM-5 Neurodevelopmental
Work Group is that, although differentiation of ASD from
typical development and other childhood disorders is done
reliably and validly, the distinction between the three cat-
egories has been found to be inconsistent and to vary across
sites (American Psychiatric Association 2011). Certainly,
this is the case in the Australian context. In our clinical
experience some assessment centers have established their
own minimum number of symptoms in order to meet cri-
teria for PDD-NOS; some require at least some sub-
threshold impairment across all three areas while others do
not. Other centers do not necessarily follow the hierarchical
process and diagnose Asperger’s Disorder in any individual
of average cognitive ability who presents with social
impairment and restricted interests. In addition to the var-
iation in application of the current criteria in relation to the
three subtypes, the vast majority of research to date has not
been able to identify meaningful differences between the
subtypes of ASD as outlined in DSM-IV-TR once cogni-
tive ability and language level have been controlled for
(e.g. Allen et al. 2001; First, 2008; Howlin, 2003; Mordre
et al. 2011).
Another proposed change in DSM-5 is reducing the
domains of impairment from three to two by merging the
social interaction and communication domains into a single
domain. This effectively means that the current eight cri-
teria in these areas will be reduced into three criteria. RRBs
will be the second DSM-5 domain and will consist of four
criteria which specifically include unusual sensory behav-
iors. In order to meet criteria for Autism spectrum disorder
under the proposed DSM-5 revision, a child must meet all
three of the social communication impairments and at least
two of the RRBs. According to the DSM-5 Neurodevel-
opmental Workgroup, the rationale for requiring at least
two symptom manifestations from RRBs is to improve
specificity (American Psychiatric Association 2011).
In a recent press release, the American Psychiatric
Association asserted that this improvement in specificity is
not at the expense of sensitivity. Specifically, they stated
that data from DSM-5 field studies do not indicate any
reduction in the number of people ‘‘receiving care for
Autism spectrum disorders in treatment centers’’ (Ameri-
can Psychiatric Association 2012). However, the DSM-5
criteria are more stringent than DSM-IV-TR, requiring a
minimum of five out of seven symptoms to be present. This
is compared to the lowest threshold for a diagnosis of an
ASD under DSM-IV-TR criteria which is currently evi-
dence of social impairment (without any specific symptom
count) and either communication impairment or RRBs or
even sub-threshold presentation across all three areas.
Therefore, there has been some concern about the impact
of the new criteria on diagnostic outcomes.
Several recent studies have indicated that the proposed
DSM-5 criteria will have a significant effect on diagnostic
rates for autism i.e. that individuals who would meet cri-
teria under DSMIV-TR will no longer meet criteria under
proposed DSM-5. McPartland et al. (2012) conducted a
re-analysis of the 933 participants evaluated for possible
pervasive developmental disorder during the DSM-IV field
trials. When they applied the proposed DSM-5 criteria to
this group, they found that 60.6 % of individuals who met
criteria under DSM-IV would meet DSM-5 criteria but
39.4 % of those who met criteria under DSMIV would no
longer meet criteria for a diagnosis of an Autism spectrum
disorder. They found that specificity of the proposed DSM-
5 was very high, with a true negative rate of 94.9 %. When
comparing cases that continued to meet and failed to meet
DSM-5 criteria, there were no differences in gender or age.
However, there was an effect for intellectual ability and
DSMIV subcategory i.e. individuals with an intellectual
disability were more likely than those without an intel-
lectual disability to meet DSM-5 criteria and individuals
with Autistic Disorder were more likely to meet DSM-5
criteria than those with Asperger’s Disorder or PDD-NOS.
The original information for this re-analysis was gath-
ered by clinicians guided by DSM-IV so it is possible that
clinicians did not gather and/or record all information that
would be considered pertinent to DSM-5 criteria. Specifi-
cally, they would not have included questions and/or
investigation of symptoms that will be included in DSM-5
but which are not included under DSM-IV-TR criteria (e.g.
indifference to pain/heat/cold, deficits in understanding
nonverbal communication). Nevertheless, these results
suggest that the proposed DSM-5 criteria may significantly
reduce the numbers of individuals diagnosed with ASD.
Similar findings in terms of reduced sensitivity for DSM-5
compared to DSM-IV criteria were also found in an earlier
epidemiological study in Finland (Mattila et al. 2011). In
this study, only 46 % of cases with an IQ C 50 that had
been identified according to DSM-IV-TR criteria met cri-
teria under the DSM-5 draft criteria. It is important to note,
however, that this study used the DSM-5 criteria posted by
the APA in February 2010, which has since undergone
some refinement.
In another recent study, Worley and Matson (2012) used
checklists to compare ASD symptoms in 121 children
classified according to both DSM-IV-TR and DSM-5
J Autism Dev Disord (2012) 42:1750–1756 1751
123
diagnostic criteria. They found that there was a subset of
children (59 out of 180 or 32.7 %) who met diagnostic
criteria for an ASD under DSM-IV-TR but no longer met
criteria under DSM-5. Furthermore, they found no signifi-
cant difference in terms of symptom severity between those
who met DSM-5 criteria and those who met DSM-IV-TR
but not DSM-5 i.e. participants who will not meet the pro-
posed future criteria had similar symptom severity to those
who will continue to meet criteria. It is important to note that
this study was based solely on parent-informant checklists
rather than on a comprehensive diagnostic assessment.
Despite this limitation, this study also provides some support
for the prediction that fewer individuals will meet the pro-
posed DSM-5 Autism spectrum disorder criteria.
There is, therefore, some uncertainty around the impact
of the proposed DSM-5 changes to the ASD diagnostic
criteria. While some preliminary research findings suggest
a reduction in the number of individuals who will meet
ASD criteria under DSM-5, the APA have indicated that
the field studies have not found any such reduction
(American Psychiatric Association 2012). Similarly, Fra-
zier et al. (2012) found similar sensitivity and improved
specificity for proposed DSM-5 criteria compared to cur-
rent DSM-IV-TR. Thus, the present study aimed to further
examine the impact of the proposed revision by comparing
diagnostic outcomes for children undergoing comprehen-
sive ASD assessment by trained clinicians cognizant of the
proposed DSM-5 criteria as of January 2011 (American
Psychiatric Association 2011). The primary research
question under consideration was whether the same clini-
cian, faced with the same information about a particular
child, would come to the same diagnostic conclusion under
both DSM-IV-TR and DSM-5 criteria. In addition, the
researchers aimed to explore the reasons for any discrepant
outcomes under the two diagnostic criteria.
Methods
Participants
The sample consisted of 132 children and adolescents referred
to a tertiary-level autism specific assessment service for an
initial diagnostic assessment for autism. Participants ranged in
age from 2 to 16 years (M = 6.06 years, SD = 3.38 years).
Eighty-one percent of participants were male (n = 107) and
19 % were female (n = 25).
Measures
The Autism Diagnostic Observation Schedule (ADOS;
Lord et al. 2002) is a semi-structured assessment tool that
measures communication ability, social interaction, and
play or imaginative skills. The ADOS consists of stan-
dardized activities that allow the clinician to observe
behaviors that have been identified as important in the
diagnosis of Autism spectrum disorders at different
developmental levels and chronological ages. The ADOS
has four modules. The clinician selects the module that is
most appropriate for the particular child or adult based on
their chronological age and expressive language level.
Administration of the ADOS took approximately 45 min.
Notes are taken during the administration of the ADOS and
the clinician assigns ratings at the completion of the
assessment. These ratings assist in the formulation of
diagnosis through the use of the diagnostic algorithm
provided for each module.
The Autism Diagnostic Interview-Revised (ADI-R;
Rutter et al. 2003) is a standardized semi-structured inter-
view that is administered to parents/caregivers regarding
the developmental history and current behavior of the
individual being assessed. The ADI-R consists of 93 items
and focuses on three function domains (language and
communication, reciprocal social interaction, and RRBs).
The administration time for each interview was approxi-
mately 2 h. The ADI–R produces an algorithm which
assists in determining whether or not an individual meets
criteria for a diagnosis of an ASD.
Procedure
The study protocol was approved by Autism Spectrum
Australia’s Ethics Committee. Informed consent was
obtained from parents prior to participation in the study.
The research was conducted during a day-long assessment
for possible Autism spectrum disorder.
The assessment consisted of informal observations, the
ADOS, and the ADI-R. The relevant ADOS module was
administered and, in the case of all children, an ADI-R was
completed with their parents. Assessments were conducted
by Psychologists and Clinical Psychologists of a special-
ized autism assessment service. All clinicians have been
trained in the use of the ADOS and ADI-R for research
purposes and administer them as a routine component of all
assessments.
Firstly, diagnosis was made according to DSM-IV-TR
criteria, with children being classified as having Autistic
Disorder, Asperger’s Disorder, PDD-NOS, or non-ASD.
The diagnostic decision was based on clinical judgment,
which was informed by scores from the ADOS and ADI-R,
along with information gathered from background reports
and teachers or other professionals. This included results of
previous cognitive assessments and/or information
regarding current level of academic functioning, which
were used to infer general cognitive ability for the purposes
of establishing the appropriateness of an Asperger’s
1752 J Autism Dev Disord (2012) 42:1750–1756
123
Disorder diagnosis. The individual’s presentation was then
considered, utilizing the same information (i.e. ADOS,
ADI-R, previous assessment reports and teacher back-
ground information) according to the proposed DSM-5
revision for Autism spectrum disorders by the same clini-
cian and a diagnosis of ASD or non-ASD was applied. Age
of onset was determined from ADI-R items pertaining to
first concerns and onset as perceived with hindsight.
Thus for each child, the same clinician using the same
information recorded two diagnostic outcomes i.e. one using
DSM-IV-TR criteria followed by one using proposed DSM-5
criteria. Where clinicians noted discrepancy between DSM-
IV-TR and DSM-5 outcomes, notes were recorded outlining
why the child did not meet criteria under DSM-5.
Data Analysis
The three ASD diagnostic categories under DSM-IV-TR were
collapsed into one group (ASD). Those who did not receive a
diagnosis under DSM-IV-TR were placed into another group
(non-ASD). These DSM-IV-TR diagnostic outcomes were
then compared with DSM-5 diagnoses. Participants were then
divided into two groups—those cases where diagnostic out-
come on DSM-IV-TR was different to outcome on DSM-5
and those cases who had the same outcome on DSM-IV-TR
and DSM-5. An independent samples t test was then utilized to
explore the relationship between the groups and age, and a
Chi-square test was used to explore the relationship between
gender and the two groups. Sensitivity was calculated as the
proportion of children who met criteria under DSM-IV-TR
who also met criteria according to DSM-5. Specificity was
calculated as the proportion of children who did not meet
criteria under DSM-IV-TR and who also did not meet criteria
under DSM-5. Notes by the clinician were also examined to
provide further information regarding the reasons for dis-
crepant outcomes on DSM-IV-TR and DSM-5.
Results
Descriptive Statistics
When considered under current DSM-IV-TR criteria, of the
132 individuals assessed, 59 (44.7 %) met criteria for
Autistic Disorder, 18 (13.7 %) met criteria for Asperger’s
Disorder, and 34 (25.7 %) met criteria for PDD-NOS. In
total, 111 of the 132 (84 %) were diagnosed with an Aut-
ism spectrum disorder under DSM-IV-TR. Twenty-one
(15.9 %) of those assessed did not meet criteria for any
ASD. Outcomes using DSM-5 criteria were then analyzed.
When considered under DSM-5 criteria, 85 (64.4 %) met
criteria for Autism spectrum disorder, while 47 (35.6 %)
did not. Table 1 outlines the diagnostic outcomes accord-
ing to DSM-IV-TR and DSM-5 criteria.
Comparison of Diagnostic Outcomes Under DSM-IV-
TR and DSM-5
Twenty-six of the 111 children (23.4 %) who received a
diagnosis under DSM-IV-TR did not meet criteria when
considered under the proposed DSM-5 criteria. The
remaining 106 children who received a diagnosis under
DSM-IV-TR retained a diagnosis of an Autism spectrum
disorder under proposed DSM-5. When the group that
retained their DSM-IV-TR diagnosis under DSM-5 was
compared to the group who did not retain their DSM-IV-
TR diagnosis under DSM-5, there was no significant dif-
ference in age, t (130) = 1.71, p = 0.09. There was also no
significant difference between the groups in gender, v2 (1,
n = 132) = 0.266, p = 0.606. Of the 26 children who did
not retain their DSM-IV-TR diagnosis under DSM-5, six
had been diagnosed with Autistic Disorder under DSM-IV-
TR, three had been diagnosed with Asperger’s Disorder,
and 17 with PDD-NOS. In order to examine whether there
was a relationship between the original DSM-IV-TR
diagnosis (i.e. Autistic Disorder, Asperger’s Disorder,
PDD-NOS) and meeting or failing to meet criteria under
DSM-5, a t test was conducted. This t test indicated that
DSM-IV-TR diagnostic sub-category was significantly
related to whether or not the child met or failed to meet
DSM-5 criteria, t (109) = -4.61, p \ 0.01. In order to
explore this further, descriptive statistics were examined.
As shown in Table 2, 10.2 % of those diagnosed with
Autistic Disorder, 16.6 % of those diagnosed with Asper-
ger’s Disorder and 50 % of those diagnosed with PDD-
NOS under DSM-IV-TR criteria failed to meet criteria for
any form of ASD under DSM-5. This indicates that,
compared to those diagnosed with Asperger’s Disorder or
Table 1 DSM-IV-TR and DSM-5 diagnostic outcomes
DSM-IV-TR diagnosis n (N = 132) % of those assessed DSM-5 diagnosis N (N = 132) % of those assessed
Autistic disorder 59 44.7 n/a
Asperger’s disorder 18 13.7 n/a
PDD-NOS 34 25.7 n/a
ASD (all above) 111 84 Autism spectrum disorder 85 64.4
Non-ASD 21 15.9 Non-ASD 47 35.6
J Autism Dev Disord (2012) 42:1750–1756 1753
123
Autistic Disorder, a higher proportion of children with
PDD-NOS under DSM-IV-TR would fail to meet criteria
under DSM-5.
Sensitivity and specificity for DSM-5 were examined to
compare these properties over the two sets of diagnostic
criteria. As shown in Table 3, when compared to DSM-IV-
TR, DSM-5 criteria had sensitivity of 0.76 and specificity
of 1.0 i.e. DSM-5 correctly identified 76 % of children with
a DSM-IV-TR diagnosis of ASD (true positives) and
100 % of the children who did not have an ASD under
DSM-IV-TR (true negatives).
In an attempt to understand why children who met cri-
teria for an ASD under DSM-IV-TR failed to meet criteria
under DSM-5, the notes of the clinician at the time of the
assessment were examined. The notes indicated that, of the
26 children who did not retain their DSM-IV-TR diagnosis
under DSM-5, 14 failed to meet criteria under DSM-5 due
to insufficient evidence of impairment in RRBs (i.e. only
satisfying 1 of the 4 criteria). The remaining 12 cases were
sub-threshold in terms of the DSM-5 social communication
domain, with the majority of this group (eight children)
displaying largely intact use of nonverbal behaviors, both
currently and according to historical record. The final four
cases did not meet full criteria for either deficits in social
emotional reciprocity or developing and maintaining rela-
tionships as set out in DSM-5.
Discussion
In this sample of 132 children referred for comprehensive
autism assessment, 26 of the 111 (23.4 %) participants who
received a diagnosis under DSM-IV-TR would not meet
criteria as proposed in DSM-5. Similar to the findings of
McPartland et al. (2012) the majority of those who would
miss out under the revised criteria came from the current
PDD-NOS group with 50 % failing to meet new criteria.
The discrepancy rates were lower for Asperger’s Disorder
and Autistic Disorder. For Asperger’s Disorder 16.6 % of
those who received a diagnosis under DSM-IV-TR would
not meet criteria under DSM-5. For Autistic Disorder the
proportion of those with discrepant outcomes was 10.2 %.
There was no relationship between the child’s age or
gender and change in diagnostic status between DSM-IV-
TR and DSM-5. Overall, specificity (or true negatives) for
DSM-5 was very high at 1.0, however this was at some cost
to sensitivity (or true positives) at 0.76.
When examining the reasons for discrepant outcomes
between DSM-IV-TR and DSM-5, 46 % of the children
who received a diagnosis under DSM-IV-TR but not DSM-
5 failed to satisfy all three of the social communication
impairments. These children demonstrated either relatively
intact non-verbal behaviors or were sub-threshold in terms
of meeting the DSM-5 criteria related to their ability to
develop and maintain relationships. The most common
reason for discrepancy in diagnostic outcome was the
failure to meet the set requirement of at least two of the
four RRBs, with 54 % of children who did not retain their
DSM-IV-TR diagnosis only satisfying one of the criteria.
In some cases this was despite presenting with a number of
unusual behaviors such as lining up objects, hand flapping
and stereotyped utterances. Under the proposed criteria all
of the above-mentioned behaviors are included in just one
of the four RRBs criteria, i.e. stereotyped or repetitive
speech, motor movements, or use of objects.
The implication is that children with marked social and
communication difficulties accompanied by several ste-
reotypical behaviors may only meet criteria for one of the
four in the RRBs and therefore not meet full criteria for an
Autism spectrum disorder diagnosis under DSM-5.
Therefore, children with clear support needs that are very
akin to an ASD may have difficulty accessing the necessary
funding, supports, and early intervention programs. This is
consistent with Worley and Matson’s (2012) findings of
similar symptom severity in children who will meet future
criteria compared to those who meet current, but not future,
criteria.
Minor changes to the proposed DSM-5 diagnostic cri-
teria could mean that some of the children whose presen-
tation is similar to that outlined above would be able to
meet all of the proposed criteria and, consequently, access
appropriate supports. For instance, our study suggests that
at least some children who just fail to meet full DSM-5
criteria would meet criteria with a reduction to the
requirement for at least two RRBs down to one RRB.
Alternatively, the creation of one additional RRB criteria
option by separating out some of the multiple behaviors
that are currently grouped together (e.g. separating out
Table 2 Breakdown of discrepant outcomes in DSM-5 by DSM-IV-
TR diagnostic category
DSM-IV-TR category n %
Autistic disorder 6 10.2
Asperger’s disorder 3 16.6
PDD-NOS 17 50
Table 3 Sensitivity and specificity of DSM-5
DSM-IV-TR DSM-5
Non-ASD ASD
Non-ASD n = 21
100 %
n = 0
0 %
ASD n = 26
23.4 %
n = 85
76.6 %
1754 J Autism Dev Disord (2012) 42:1750–1756
123
repetitive use of objects from stereotyped language and
motor movements) would allow for additional diagnoses.
These findings would indicate that, without any further
changes, DSM-5 is likely to reduce the number of children
who will be diagnosed with an ASD in the future due to the
more stringent requirements in terms of the number of
criteria that must be met. Results from this study suggest
that the children likely to fall short of meeting full DSM-5
criteria are those who met DSM-IV-TR criteria for PDD-
NOS. The findings highlight the need for comprehensive
assessment, with multiple sources of information including
clinical observation, and information from parents, teach-
ers and other professionals involved with the child. This is
to ensure that adequate information is obtained in order to
satisfy the higher proportion of criteria that will need to be
met under DSM-5.
The rationale behind many of the changes in DSM-5 is
to improve diagnostic consistency and increase the stability
of ASD diagnoses over time. It is possible that many of the
children who would no longer meet ASD criteria under
DSM-5 would instead meet criteria for a diagnosis of the
proposed DSM-5 Social Communication Disorder (SCD).
SCD is conceptualized as a communication disorder and is
characterized by impairments in pragmatics. The propor-
tion of children in this study who may have met criteria for
SCD was not examined as the criteria for SCD have not yet
been clearly operationalized. It could be that this group is,
in fact, quite distinct from those who will meet formal ASD
criteria in DSM-5 with meaningful differences in outcome
and intervention. Alternatively, this group may actually be
more closely aligned to those who meet the full DSM-5
criteria. Future research should aim to examine the simi-
larities and differences between Autism spectrum disorder
as defined in DSM-5 and the proposed Social Communi-
cation Disorder. It is important to examine this, as it would
have implications for the development and implementation
of effective, targeted intervention programs.
There are several limitations to this study that should be
acknowledged. Firstly, there are a number of behaviors that
have long been associated with ASDs that were not for-
mally outlined in DSM-IV-TR and are now included in
DSM-5, e.g. difficulties understanding non-verbal behav-
iors, hypersensitivity to sensory input, indifference to pain/
heat/cold. The assessment tools utilized in this study are
based on DSM-IV-TR criteria. Therefore, information
relating to these newer behaviors may not have been elic-
ited during the assessment process and may have resulted
in an over-estimate of the numbers of children who would
miss out on a DSM-5 diagnosis of ASD. However, clinical
experience is that even without direct questioning, when
these behaviors are evident in a child’s presentation, they
are often volunteered by parents at some point during the
assessment process. Nevertheless, future research into the
effects of the proposed criteria should specifically probe for
new behaviors included in DSM-5. Secondly, the nature of
the sample may limit the generalizability of the results.
That is, as a tertiary referral service many of the cases
represent what may be considered subtler presentations
and/or presentations that may be complicated by the pres-
ence of significant co-morbidities. It could be that the
proportion of those who would not meet criteria for a
DSM-5 diagnosis may be less if cases are taken across the
wider community. Further research utilizing a larger sam-
ple size across a wider community sample would provide
more information. Finally, consideration of a diagnosis
under DSM-5 was always conducted after reaching a
decision according to DSM-IV-TR in this study. Future
studies could evaluate whether arriving at a decision
according to DSM-5 prior to DSM-IV-TR would affect
results.
In conclusion, our findings indicate that there will be
some children who will no longer meet criteria for an ASD
under DSM-5 despite meeting DSM-IV-TR criteria. This
will most likely be those who would currently be diagnosed
with PDD-NOS. As these children do have significant
social communication difficulties, it is possible that they
would meet criteria for SCD. Future research is required to
determine the impact of changes to the diagnostic criteria
on prevalence rates for ASD, funding and treatment
implications, diagnostic practices and comparative out-
comes for children with ASD and SCD.
Acknowledgments This research was presented at the Asia Pacific
Autism Conference (APAC) which was held in Perth, Australia from
8th to 10th of September 2011.
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