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Autism in the DSM

DSM (1952)

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The following information describes the history of autism in the Diagnostic and Statistics Manual (DSM), the manual that details the criteria for different psychological conditions. The DSM is now on its 5th revision.​ Note that material presented in "quotes" are directly taken from the source material.

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The term "autism" first appeared in the DSM in 1952 as “schizophrenic reaction, childhood type” (000-x28) to refer to schizophrenia-like behaviours that occurred before the onset of puberty.  The DSM included this category under schizophrenia on account of the young age of the child and the immense amount of brain plasticity that occurs during the early years of life. The authors of this section felt that younger children may present differently from older youth/adults with schizophrenia

DSM-II (1968)

Autism continued to fall within a childhood presentation of schizophrenia in the DSM-II (1968) [295.8 Schizophrenia, childhood type]. New in version II was that autism could be associated with intellectual development disorder:
 

This category is for cases in which schizophrenic symptoms appear before puberty. The condition may be manifested by autistic, atypical and withdrawn behavior… may result in [intellectual developmental disorder], which should also be diagnosed” (language of the DSM-II)

During this era of Autism history, Autism was thought of as a form of childhood schizophrenia, caused by "refrigerator mothers" who were viewed as (emotionally cold. Children were believed to withdraw "to escape  their parents cold nature".  Proponents of this view included Abbate, Bettelheim, Garcia and Sarvis, amongst others.  Clinicians began to disagree with this view and started to explore biological influences on the development of autism.  Rimland was the first to conceptualize autism as a "biologically based, neurological  disorder" in 1964, noting the idea of refrigerator mothers was both incorrect and harmful  (Fishbein et al. 2017)

 

DSM-III (1980)

Autism was first referred to as a separate and unique diagnosis not connected with schizophrenia in the DSM-III (1980). “Infantile Autism” was conceptualized as a childhood condition and  required:

  1. “Onset before 30 months of age”,  

  2. The child shows a “pervasive lack of responsiveness to other people (autism)”,  

  3. There is a delay/absence of spoken language [if present, atypical “speech patterns such as immediate echolalia…” are seen],  and

  4. The child has responses “to various aspects of the environment, e.g., resistance to change…”

 

The child also must have an “absence of delusions, hallucinations, loosening of associations, and incoherence as in Schizophrenia”

DSM-III-TR (Text Revision; 1987)

The medical and research understanding of Autism expanded in the DSM-III-TR (1987) to include “Autistic Disorder.” The idea of a spectrum was beginning to emerge, with children requiring 8 out of 16 possible criteria to be diagnosed. These were broken down across three different categories (A, B, and C). These categories broadly described a condition that was manifested by an absence or lack of skill.

Category A - had to present with at least 2 of the following
Qualitative impairment in reciprocal social interaction” as manifested by a limited ability or lack of:

  • Awareness of others’ feelings”, 

  • Seeking of comfort when distressed,

  • Imitation of others’ actions,

  • Social play with others, or

  • Friendships

 

Category B - had to present with at least 1 of the following

Qualitative impairment in verbal and nonverbal communication and in imaginative activity” as manifested by a limited ability or lack of:

  • “Modes of communication”

  • Nonverbal communication (e.g., differences in eye contact) to modulate interactions,

  • “Imaginative play,” as well as 

  • Differences in speech production (e.g., volume, rhythm, tone),

  • Differences in form or speech content (e.g., echolalia and scripting), or

  • Difficulties beginning or sustaining a conversation with others 

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Category C - had to present with at least 1 of the following

 “Markedly restricted repertoire of activities and interests” which could include

  • “Stereotyped body movements” (e.g., spinning),  

  • Intense attention on parts of objects (e.g., wheels on cars),

  • Distress over small changes,

  • Insistence on following routines, or

  • “Restricted range of interest” (a lot of facts about a topic)​

Trigger warning - behavioural treatment

Behavioural treatments took hold during this era in Autism history. Although the roots of behavioural interventions for autism can be traced back to the 1960s, ABA (applied behavioural analyses) gained ground in the 1980s following a report by Lovaas in 1987 - a 15 year longitudinal study noting the "significant increases in the cognitive functioning of children with autism."  Further taking hold as the premier treatment for autism,  Iwata and colleagues touted the benefits of ABA on the treatment of "self-injurious behaviour" in 1994. (Fishbein et al. 2017)

Note: ABA has been reported to be harmful by the autistic community. The Autistic Self Advocacy Network (ASAN) have stated, " ABA uses rewards and punishments to train autistic people ... ABA and other therapies with the same goals can hurt autistic people, and they don’t teach us the skills we actually need to navigate the world with our disabilities. (ASAN, 2024) ' 

DSM-IV (1994) and DSM-IV-TR (text revision; 2000)

DSM-IV (1994) and DSM-IVR (2000) introduced Asperger’s Disorder. Asperger's Disorder was characterized by two broad categories and additional requirements:

 

Asperger's Disorder

Category A

Qualitative differences in social interaction as indicated by two of the following:

  • Use of multiple nonverbal behaviours (such as eye contact and facial expression),

  • Developing peer relationships,

  • Spontaneously sharing enjoyment, interests, or achievements with other people, and 

  • Social or emotional reciprocity

 

Category B

Presence of restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, as indicated by at least one of the following:

  • Preferred (special) interest,

  • Adherence to routines and rituals,

  • Repetitive motor movements, or 

  • Preoccupation with parts of objects

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C. Must causes clinically significant challenges in social, occupational, or other important areas of functioning.

D. There is no clinically significant delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years).

E. There is no clinically significant delay in cognitive development or adaptive behaviour (other than in social interaction)

F. Criteria are not met for another specific pervasive developmental disorder or schizophrenia

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DSM-IV (1994) and DSM-IVR (2000) further refined their definition of Autistic Disorder (299.00) to require at least 6 traits, with 2 behaviours required from A and 1 each required from B and C to meet criteria. 

 

Autistic Disorder​

Category A

Qualitative differences in social interaction, as indicated by at least two differences in:

  • Use of multiple nonverbal behaviors, such as eye contact and facial expression,

  • Developing peer relationships,

  • Spontaneous seeking to share enjoyment, interests, or achievements with others, or

  • Social or emotional reciprocity

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Category B

Qualitative differences in communication as indicated by at least one difference in:

  • The development of spoken language,

  • For individuals with speech, differences in the ability to initiate or sustain a conversation with others,

  • ‘Stereotyped’ use of language or idiosyncratic language, and

  • Spontaneous make-believe play or social imitative play 

 

Category C

Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities” as indicated by at least one difference in:

  • Having a ‘preoccupied interest’,

  • Adherence to specific, routines or rituals,

  • ‘Stereotyped’ and repetitive motor mannerisms,

  • Preoccupation with parts of objects


Must be delays or differences in at least one of the following areas, prior to age 3 years:

  1. Social interaction,

  2. Language as used in social communication, or

  3. Symbolic or imaginative play

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Also Included categories for 

299.80 Rett’s Disorder 

299.10 Childhood Disintegrative Disorder

299.80 Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS)​​


This was the only version of the DSM in which Asperger's Disorder  (also referred to as Asperger's Syndrome or Asperger's) appeared. In following version (DSM-5), Asperger's Disorder was grouped with Autistic Disorder to form one umbrella diagnosis:  "Autism Spectrum Disorder."

Trigger Warning: Asperger, the person.
Hans Asperger had ties to the Nazi party and was complicit in the loss of life of many children under the Third Reich (Baron Cohen, 2018). As such, the term Asperger's is considered controversial by many, with others still separating it from the man and considering the term as a part of their identity (Aspie, n.d.). 

DSM-5 (2013) 

They switched from Roman numerals to numbers with the 5th edition. 

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The different categories in the DSM-IV and DSM-IV-TR were collapsed in the DSM-5 into one umbrella term – Autism Spectrum Disorder (299.00). There are two categories of features that one must experience. 


Category A - Person must experience all 3 

Persistent challenges with social communication and social interaction as indicated by differences in all of the following:

  1. Social-emotional reciprocity (initiate and respond to social interactions),

  2. Nonverbal communicative behaviours used for social interaction (integrating verbal and nonverbal communication), and 

  3. Developing, maintaining, and understand relationships

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Category B - Person must experience at least 2 of the following 4

 ‘Restricted, repetitive patterns of behavior, interests, or activities’, as indicated by at least two of the following:

  1. ‘Repetitive’ motor movements, use of objects, or speech (lining up toys; echolalia),

  2. Insistence on sameness, needing routines, or patterns of verbal or nonverbal behavior (distress at small changes, need to take same route),

  3. Interests that are different in intensity or focus, or

  4. Hyper- or hypo-reactivity to sensory input or interest in sensory aspects of the environment​

 

Also noted as required is: 
C. Features must be present (but not necessarily fully manifested) in the early developmental period 

D. Symptoms cause clinically significant challenges in social, occupational, or other important areas of current functioning

E. These challenges are not better explained by an intellectual developmental disorder or global developmental delay​​

References

​American Psychiatric Association. (1952). Diagnostic and statistical manual of mental disorders.​

American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (2nd ed.).​

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.).

​American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.).

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.).

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Autistic Self-Advocacy Network (2024). What we believe. Author. 

       https://autisticadvocacy.org/about-asan/what-we-believe/

Aspie. (n.d.). About ASPIE. https://aspie.org.uk/about-aspie/

Baron Cohen, S. (2018). The truth about Hans Asperger's Nazi collusion. Nature.
        https://www.nature.com/articles/d41586-018-05112-1

Fishbein, L. B., Rouse, M. L., Minshawi, N. F., & Foisted, J. C. (2017). Historical development of treatment. In J. L. Mason        
     (ed.), Handbook of Treatments for Autism Spectrum Disorder. Springer International Publishing.
      https://doi.org/10.1007/978-3-319-61738-1_1 

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