Historical perspective

Over the past year, newspapers, blogs and scientific journals have been publishing rousing debates over how autism is, and should be, diagnosed. The writers have been mostly reacting to proposed changes in the official diagnostic criteria for autism, intended to be put into practice in 2013. 

But in fact these debates have been percolating for decades, according an editorial published 16 July in the Journal of Child Psychology and Psychiatry.

Sally Ozonoff highlights 12 papers published since the first edition of the journal, in 1961, that trace the changing definitions of autism and related disorders.

The newest version of the field’s diagnostic bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), due out next May, proposes a number of significant changes to how these disorders are diagnosed.

The most controversial of the proposals is to bring several disorders — including Asperger syndrome and pervasive developmental disorder-not otherwise specified — under the single heading of autism spectrum disorder.

Critics are concerned that the new criteria will exclude some people with these diagnoses, though initial reports from the DSM-5 Neurodevelopmental Disorders Work Group suggest this is not the case.

“As I hope this editorial will make clear, the changes are anything but capricious or arbitrary,” Ozonoff, who is not a member of the work group, writes. She says the 12 papers represent an evolving understanding of these disorders and how they should be grouped.

In fact, she says, it was challenging to find papers that support a “DSM-as-usual” approach and easier to find those that support the new criteria.

For example, two papers published in the 1990s highlight that the “boundaries between DSM categories are not nearly as tidy as envisioned and hoped.”

Ozonoff herself published questions over the designation of Asperger disorder soon after an influential 1995 paper suggested that autism and Asperger syndrome have different neuropsychological profiles. She found that four of the cases described in the original paper meet the criteria for autistic disorder, the DSM-IV designation for what we think of as classic autism. A number of papers with similar conclusions followed.

Ozonoff does disagree with one proposed change: the creation of a new category, called social communication disorder, for children whose symptoms do not include repetitive behaviors. She and others have questioned whether this condition is truly distinct from autism.

“Let’s not take two steps forward and one step back,” she writes.