Commentary on the Application of DSM-5 Criteria for Autism Spectrum Disorder

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Back to table of contents Previous article Next article Communications and UpdatesFull AccessCommentary on the Application of DSM-5 Criteria for Autism Spectrum DisorderEdward R. Ritvo, M.D., and Riva Ariella Ritvo, Ph.D.Edward R. RitvoSearch for more papers by this author, M.D., and Riva Ariella RitvoSearch for more papers by this author, Ph.D.Published Online:1 Apr 2013https://doi.org/10.1176/appi.ajp.2013.12101376AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In the introduction of the article by Huerta et al. in the October 2012 issue of the Journal (1), the authors cite several published studies indicating that the proposed DSM-5 criteria for autism spectrum disorder (ASD) would exclude approximately 10%–50% of patients currently meeting DSM-IV criteria. These patients would become ineligible for services if clinics required a rediagnosis meeting the new criteria (a common occurrence), and a similar proportion of newly diagnosed patients would be “dropped out” and denied services.To assess this serious issue, Huerta et al. set out to determine the sensitivity and specificity of the proposed DSM-5 criteria relative to the DSM-IV criteria. They utilized three data sets including 4,453 children with a DSM-IV clinical diagnosis of pervasive developmental disorder (PDD) and 690 with non-PDD diagnoses (e.g., language disorder). They reported an overall sensitivity of 0.91 and a specificity of 0.53 for the proposed DSM-5 criteria.The authors concluded, “Our findings indicate that the majority of children with DSM-IV PDD diagnoses would continue to be eligible for an ASD diagnosis under DSM-5,” thus implying that their data support instituting the proposed DSM-5 changes.We respectfully disagree with their opinion regarding the usefulness of the proposed DSM-5 criteria based on their data. Abandoning criteria that have been in worldwide use for decades for new ones that may eliminate from 9% (their data) to >40% (prior reports) of previously diagnosed patients is neither scientifically nor morally justified.Also, the specificity values they computed for the new criteria averaged only 0.53. This figure is unacceptably low by typical medical test standards.It is also important to point out that the data set used by the authors contained only 238 case subjects with Asperger’s disorder among all 4,453 children meeting DSM-IV criteria. Thus, only a small number (0.53%) of those compared with the DSM-5 criteria were those most likely to be eliminated according to the prior studies they cited. This makes the observed specificity and sensitivity higher than they would have been if those known to be most likely to be excluded were in fact excluded before the study began.We also wish to point out another serious unintended consequence of instituting the proposed DSM-5 criteria—the obvious problem posed to all researchers when selection criteria for subjects are changed. We have amassed large, detailed, uniformly diagnosed subject pools at great effort and expense over the past four decades. Changing diagnostic criteria would make those subject data pools incompatible and unusable for studies involving individuals diagnosed by new criteria who will be enrolled in our ongoing and future clinical and biomedical research projects.In conclusion, the results presented by the authors do not support instituting the DSM-5 criteria and can cause harm to our patients and research projects. Furthermore, the proposed changes rest on clinical data, and any changes should be postponed until new, replicable biomedical data warrant such a major undertaking.From the Neuropsychiatric Institute, University of California Los Angeles, and the Yale Child Study Center, New Haven.The authors report no financial relationships with commercial interests.Reference1 Huerta M, Bishop SL, Duncan A, Hus V, Lord C: Application of DSM-5 criteria for autism spectrum disorder to three samples of children with DSM-IV diagnoses of pervasive developmental disorders. Am J Psychiatry 2012; 169:1056–1064Link, Google Scholar FiguresReferencesCited byDetailsCited ByPerinatal issues for women with high functioning autism spectrum disorderWomen and Birth, Vol. 30, No. 2Journal of Autism and Developmental Disorders, Vol. 47, No. 9Update on diagnostic classification in autismCurrent Opinion in Psychiatry, Vol. 27, No. 2A novel conceptual framework for psychiatry: vertically and horizontally integrated approaches to redundancy and pleiotropism that co-exist with a classification of symptom clusters based on DSM-530 July 2013 | Molecular Psychiatry, Vol. 18, No. 8BMC Medicine, Vol. 11, No. 1 Volume 170Issue 4 April 2013Pages 444a-445 Metrics PDF download History Accepted 1 January 2013 Published online 1 April 2013 Published in print 1 April 2013