Wednesday, July 13, 2011

Autism: Disorder or Condition?

Autism is variously viewed as a psychiatric disorder, mental disorder, and mental disability by the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association [APA], 1994) and International Classification of Diseases (World Health Organization, 1993). The requirements for all disorders in the DSM-IV are "evidence" of personal distress, functional impairment, or contribution to personal risk of loss. The boundary between normality (or typicality) and pathology is conceptualized as a “clinically” significant behavioral or psychological syndrome that occurs within an individual and is associated with a disability (or impairment in one or more areas of functioning). The clinician’s task in using the DSM classification system is to determine whether the problems presented by the individual can be reasonably conceptualized as a mental "disorder" within this context.
The pervasive developmental disorders (PDD) have traditionally been viewed as categorical rather than dimensional systems of classification (diagnoses). With a categorical or dichotomous scheme, disorders are either present or absent (e.g., an individual meets or does not meet criteria). For example, the DSM-IV-TR and ICD-10 list specific criteria for each disorder that must be met to receive a diagnostic classification. They both focus on a description of behavior rather than its function. 
Researchers and practitioners now posit that autism falls on a continuum and that there is no clear distinction between “mild autism” and the boundaries of neurotypicality (or normalcy). In fact, we now recognize that autism-related traits are normally distributed throughout the general population and that autism is best conceptualized as a spectrum of severity. As Lorna Wing comments, “All of the features that characterize Asperger syndrome can be found in varying degrees in the normal population.” According to the extant literature, the accepted terminology is to use autism spectrum disorder or the acronym ASD as an umbrella term to describe individuals with Asperger’s Disorder (Syndrome), high-functioning autism (HFA), and PDD-NOS.  

Nevertheless, experts such as Baron-Cohen (2008) contend that the term autism spectrum condition (ASC) is preferable to ASD as this term concurrently recognizes both the disabling aspects of autism and a profile of strengths (e.g., non-social skills). As with any “condition,” an autism spectrum condition may or may not be disabling. This includes groups of more successful individuals in the general population who present with sub-clinical (or sub-threshold) features of ASD. While individuals who have autistic traits certainly think and perceive differently than typical individuals, they may not be significantly impaired. An individual may demonstrate mild qualitative differences in social skills, yet not meet the clinical criteria for an autism-related condition such as high-functioning autism or Asperger’s disorder (syndrome). While a person’s social skills might be below average relative to his or her age group, these differences may not result in what might be considered to be a “global” disability or impairment. Moreover, there are individuals without a diagnosis who have marked difficulties, while others with a diagnosis have only mild problems. Despite the considerable variation in the profiles of individuals with autism, it is when these “differences” in social functioning lead to an impairment in adaptability (e.g., personal, occupational) and the need for clinical services, that we describe the individual as having a disorder. This includes the commonly co-occurring (or comorbid) disorders such as anxiety and depression.
So, we return to the question, Disorder or Condition? It would seem that the term “condition” is more compatible with the dimensional view of autism. It reflects the assumption that autistic traits exist on a continuum and that they are normally distributed throughout the general population (e.g., we all have some autistic traits). Using the term autism spectrum condition (ASC) also communicates a “value-free” or neutral perception as opposed to the negative impression associated with disorder or disability. Lastly, the term condition acknowledges that individuals with ASC may also possess positive traits, thus encouraging a strength-based perspective.

Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers.

©Lee A. Wilkinson


Pete Quinn said...

Thanks Lee.

I think you'd be interested in this blog post by Dorothy Bishop and respondants to it:

Pete Quinn said...

Very interesting. Thanks.

Tricia Johnson said...

MY AS daughter prefers to refer to her place on the spectrum as a "state of being." For her (and subsequently us) this better states how things are for her since the word "disorder" is strongly suggestive of something wrong and she's resistant to the idea that something is "wrong" with her. She sees her AS state of being as an asset and would that more of the world was like her in that regard. I, as her parent, do see the disadvantages her state of being sometimes presents, but we all have disadvantages to overcome. That is subjective at the very least.

Thanks for this article! Great food for thought.

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