Autism spectrum disorder and speech delay with use of compensation v.s. without

[Chrysanthemum]

So I have read that the difference between "high-functioning autism" (I know it's not an official diagnostic label) and Asperger's is that high-functioning autism includes speech delay whereas Asperger's doesn't. However, while thinking about this, I thought of something: according to the DSM-IV, the "impairment in communication" criteria of which one mentioned must be met to be diagnosed with "Autistic Disorder" includes:

"
2. Qualitative impairments in communication as manifested by at least one of the following:

a. delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime).

b. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others.

c. stereotyped and repetitive use of language or idiosyncratic language.

d. lack of varied, spontaneous, make-believe play or social imitative play appropriate to developmental level."

Not all of these "qualitative impairments", of which only one needs to be met for "Autistic Disorder" prior to 2013, necessitates spoken language delay; also, one of the "impairments" mention a spoken language delay but "not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime". So it seems that it is possible for an individual to have autism and be labelled as "high-functioning" without language delay, but also that even if they did have significant language delay, if they did compensated through "alternative modes of communication" such as "gestures or mime" (also I'm just wondering does writing count as an "alternative modes of communication" because I think it actually is one) without having the other listed communication impairments they wouldn't meet the criteria for "Autistic Disorder" (maybe would for PDD-NOS)? And if it's delay in spoken language without compensation why didn't they just say delay in ALL communication (including non-verbal communication)?

 

[Crossbreed]

Most people won't debate the particulars of DSM-4 since we are now in the era of DSM-5.

The current diagnosis is Autism Spectrum Disorder with severity levels 1 [least] to 3 [most]. (The severity levels are actually a grade of one's co-morbid conditions.)

DSM-5:______ASD1_____ASD2_____ASD3
Colloquial:___High-func__Mid-func___Low-func
DSM-4:______Aspergers__HF-Autism_LF-Autism

 

[Darwin]

Most people won't debate the particulars of DSM-4 since we are now in the era of DSM-5.

The current diagnosis is Autism Spectrum Disorder with severity levels 1 [least] to 3 [most]. (The severity levels are actually a grade of one's co-morbid conditions.)

DSM-5:______ASD1_____ASD2_____ASD3
Colloquial:___High-func__Mid-func___Low-func
DSM-4:______Aspergers__HF-Autism_LF-Autism

I agree.
I am not even comfortable with using colloquial terms because they were not mentioned in the DSM V. I think we should stop using the old terms, and only talk about the level of ASD.

@Chrysanthemum

In the DSM V, there is a nice table that differentiates between the three levels, 1, 2 and 3 based on the amount of support a person needs in his/her life. For example, in ASD 1, the person only needs minimal support. I am not going to go through details, so if you’re interested, check the part about ASD in the DSM V. You will find the table after the Discussion section.

 

[Chrysanthemum]

Thank you for your replies and your points and I really appreciate you sharing them. I don’t think “high-functioning autism” was mentioned in the DSM-IV” either but was just wondering about how it seems in the DSM-IV in the absence of other verbal communication impairments seems like you have to have to have an absence of “alternative modes of communication” like no gesture or miming in addition to spoken language absence or delay, along with social difficulties and restricted/repetitive behavior to be diagnosed with “Autistic Disorder”. I was aware that the DSM V is used now and contains “severity labels”. But I raised the question because I had diagnostic assessments done before the era of DSM-V not after DSM-IV also I don’t know whether or not all countries use the DSM-V I’ve also heard about ICD-10?

I am just a layman but in the context of the DSM-V I feel that it is possible for “severity labels” to change too especially in children, like maybe a 3 year old who is rather non-responsive and minimally verbal or even nearly or totally non-verbal might develop strong language skills and have much improved social skills, so I’m wondering are very young children also going to be given “severity labels” (not saying it might not be useful in the current context of the child’s situation but just hopefully not taken like a “predictor” of the child’s future)? Also if a child, teenager or adult needs level 1 support in managing social-communication and social-interaction challenges but level 3 support in managing restricted and repetitive behavior or vice versa, what would their severity label be?

Also with the severity labels it seems that it assumes that everyone with ASD needs additional support otherwise they don’t have ASD unless they’re saying ever needing any additional support not must currently require additional support?

“Crossbreed” what do you mean by “The severity levels are actually a grade of one's co-morbid conditions”?

I found the DSM-V diagnostic criteria here: Diagnostic Criteria | Autism Spectrum Disorder (ASD) | NCBDDD | CDC

 

[Crossbreed]

I don’t think “high-functioning autism” was mentioned in the DSM-IV” either.

The DSM-4 had

• Asperger's Syndrome [AS] which was autism without any significant speech or cognitive delay, and
• [Kanner's] Autism which did have delays in one or both arenas.

When it came to practical therapy, Kanner's was informally divided into two sub-categories,

• High-Functioning Autism [HFA], for those who could dialogue with their therapist, and
• Low-Functioning Autism [LFA], for those who could not.

Part of the problem with that system was that no one could agree on the line where HFA ended and AS began.

DSM-5's severity levels addressed that. AFAIK, only one severity level is given in view of all of a person's support needs, not for their particular needs.

Many members, here, know the meaning of ASD1, ASD2 & ASD3, but when a therapist explains it to someone who is unfamiliar with these terms, they will say high-, mid- or low-functioning autism just for simplicity's sake.

“Crossbreed” what do you mean by “The severity levels are actually a grade of one's co-morbid conditions”?

See Autlanders, Thriving Outside of the Box: Autism Subtypes...

(Feel free to ask again, if that post doesn't clearly answer your question.)

 

[Darwin]

I don’t think “high-functioning autism” was mentioned in the DSM-IV” either but was just wondering about how it seems in the DSM-IV in the absence of other verbal communication impairments seems like you have to have to have an absence of “alternative modes of communication” like no gesture or miming in addition to spoken language absence or delay, along with social difficulties and restricted/repetitive behavior to be diagnosed with “Autistic Disorder”. I was aware that the DSM V is used now and contains “severity labels”. But I raised the question because I had diagnostic assessments done before the era of DSM-V not after DSM-IV also I don’t know whether or not all countries use the DSM-V I’ve also heard about ICD-10?

DSM is the one used in the US. ICD is published by the WHO. I honestly have not checked the ICD yet, so I don’t know whether they have the same criteria for ASD or not.

I am just a layman but in the context of the DSM-V I feel that it is possible for “severity labels” to change too especially in children, like maybe a 3 year old who is rather non-responsive and minimally verbal or even nearly or totally non-verbal might develop strong language skills and have much improved social skills, so I’m wondering are very young children also going to be given “severity labels” (not saying it might not be useful in the current context of the child’s situation but just hopefully not taken like a “predictor” of the child’s future)? Also if a child, teenager or adult needs level 1 support in managing social-communication and social-interaction challenges but level 3 support in managing restricted and repetitive behavior or vice versa, what would their severity label be?

I think, almost every autistic improves in his/her social skills and other aspects as they grow up. It’s not clear in the DSM if the diagnosis is “improved,” but a child diagnosed with level 3 ASD at 5 y/o would not develop the same “level” of social skills at 10 y/o as that another child with ASD-1 will develop at the same age; they will, throughout their life, require different amounts of support.

Also with the severity labels it seems that it assumes that everyone with ASD needs additional support otherwise they don’t have ASD unless they’re saying ever needing any additional support not must currently require additional support?

Yes. One of the main criteria is that daily functioning must be affected in some way or another. That’s what disorder in Autism Spectrum Disorder means. It has the same meaning in Major Depressive Disorder, Anxiety Disorder, etc.

 

[Crossbreed]

I think, almost every autistic improves in his/her social skills and other aspects as they grow up.

There are stories (like Temple Grandin) where there is marked functional improvement with age. (ASD1's are better at masking.)

There are others (like my ASD2 son, ASD3 daughter & Susie Wing) who never improve.

 

[Pats]

In the DSM V under level II one of the criteria listed is this: "Social impairment even with support in place." I don't understand what kind of support this means.

 

[Alexej]

ICD - 10 extract

F84 Pervasive developmental disorders

A group of disorders characterized by qualitative abnormalities in reciprocal social interactions and in patterns of communication, and by a restricted, stereotyped, repetitive repertoire of interests and activities. These qualitative abnormalities are a pervasive feature of the individual's functioning in all situations.

Use additional code, if desired, to identify any associated medical condition and mental retardation.

F84.0 Childhood autism

A type of pervasive developmental disorder that is defined by: (a) the presence of abnormal or impaired development that is manifest before the age of three years, and (b) the characteristic type of abnormal functioning in all the three areas of psychopathology: reciprocal social interaction, communication, and restricted, stereotyped, repetitive behaviour. In addition to these specific diagnostic features, a range of other nonspecific problems are common, such as phobias, sleeping and eating disturbances, temper tantrums, and (self-directed) aggression.

Autistic disorder
Infantile:
· autism
· psychosis
Kanner syndrome

Excl.:
autistic psychopathy (F84.5)

F84.1 Atypical autism

A type of pervasive developmental disorder that differs from childhood autism either in age of onset or in failing to fulfil all three sets of diagnostic criteria. This subcategory should be used when there is abnormal and impaired development that is present only after age three years, and a lack of sufficient demonstrable abnormalities in one or two of the three areas of psychopathology required for the diagnosis of autism (namely, reciprocal social interactions, communication, and restricted, stereotyped, repetitive behaviour) in spite of characteristic abnormalities in the other area(s). Atypical autism arises most often in profoundly retarded individuals and in individuals with a severe specific developmental disorder of receptive language.

Atypical childhood psychosis
Mental retardation with autistic features
Use additional code (F70-F79), if desired, to identify mental retardation.

F84.2 Rett syndrome

A condition, so far found only in girls, in which apparently normal early development is followed by partial or complete loss of speech and of skills in locomotion and use of hands, together with deceleration in head growth, usually with an onset between seven and 24 months of age. Loss of purposive hand movements, hand-wringing stereotypies, and hyperventilation are characteristic. Social and play development are arrested but social interest tends to be maintained. Trunk ataxia and apraxia start to develop by age four years and choreoathetoid movements frequently follow. Severe mental retardation almost invariably results.

F84.3 Other childhood disintegrative disorder

A type of pervasive developmental disorder that is defined by a period of entirely normal development before the onset of the disorder, followed by a definite loss of previously acquired skills in several areas of development over the course of a few months. Typically, this is accompanied by a general loss of interest in the environment, by stereotyped, repetitive motor mannerisms, and by autistic-like abnormalities in social interaction and communication. In some cases the disorder can be shown to be due to some associated encephalopathy but the diagnosis should be made on the behavioural features.

Dementia infantilis
Disintegrative psychosis
Heller syndrome
Symbiotic psychosis
Use additional code, if desired, to identify any associated neurological condition.

Excl.:
Rett syndrome (F84.2)

F84.4 Overactive disorder associated with mental retardation and stereotyped movements

An ill-defined disorder of uncertain nosological validity. The category is designed to include a group of children with severe mental retardation (IQ below 35) who show major problems in hyperactivity and in attention, as well as stereotyped behaviours. They tend not to benefit from stimulant drugs (unlike those with an IQ in the normal range) and may exhibit a severe dysphoric reaction (sometimes with psychomotor retardation) when given stimulants. In adolescence, the overactivity tends to be replaced by underactivity (a pattern that is not usual in hyperkinetic children with normal intelligence). This syndrome is also often associated with a variety of developmental delays, either specific or global. The extent to which the behavioural pattern is a function of low IQ or of organic brain damage is not known.

F84.5 Asperger syndrome

A disorder of uncertain nosological validity, characterized by the same type of qualitative abnormalities of reciprocal social interaction that typify autism, together with a restricted, stereotyped, repetitive repertoire of interests and activities. It differs from autism primarily in the fact that there is no general delay or retardation in language or in cognitive development. This disorder is often associated with marked clumsiness. There is a strong tendency for the abnormalities to persist into adolescence and adult life. Psychotic episodes occasionally occur in early adult life.

Autistic psychopathy
Schizoid disorder of childhood

F84.8 Other pervasive developmental disorders

F84.9 Pervasive developmental disorder, unspecified

F88 Other disorders of psychological development

Incl.:
Developmental agnosia

F89 Unspecified disorder of psychological development

Incl.:
Developmental disorder NOS

 

[Crossbreed]

I don't understand what kind of support this means.

From my experience, such support is helpful, but not particularly therapeutic. The patient's functioning level is not improved.

 

[Pats]

From my experience, such support is helpful, but not particularly therapeutic. The patient's functioning level is not improved.

But with social communication, what exactly would they be doing that's considered support? Does it mean talking for the person? Chalk board for writing? It's just not coming to me what it could possibly involve.

 

[Crossbreed]

Does it mean talking for the person?

Largely.

Chalk board for writing?

Such would be a long-term fix, thus therapeutic.

 

[Chrysanthemum]

Largely.

Such would be a long-term fix, thus therapeutic.

I'm just wondering in what ways do your children's autism spectrum disorder manifest and are they verbal at all and if so to what extent? If not how good is their non-verbal communication?

If you don't feel comfortable answering this, that's fine.

 

[Crossbreed]

I'm just wondering in what ways do your children's autism spectrum disorder manifest and are they verbal at all and if so to what extent? If not how good is their non-verbal communication?

My ASD3 daughter has all of the normal functions of a not-yet-verbal, 18mo toddler, in the body of a 25yo woman. She is my ward.

My ASD2 son (32) has the functioning level of a 6-10yo. He does not grasp cause & effect/consequences. (My daughter, above, gets that somewhat better than he does.) Because he is verbal, he does not have a guardianship, but he does have a representative payee to make sure that his bills get paid, first, before turning the remainder of his money over to him.

 

[Chrysanthemum]

My ASD3 daughter has all of the normal functions of a not-yet-verbal, 18mo toddler, in the body of a 25yo woman. She is my ward.

My ASD2 son (32) has the functioning level of a 6-10yo. He does not grasp cause & effect/consequences. (My daughter, above, gets that somewhat better than he does.) Because he is verbal, he does not have a guardianship, but he does have a representative payee to make sure that his bills get paid, first, before turning the remainder of his money over to him.

By "functioning level" do you mean in social interaction, daily living or intellectual functioning?

 

[Chrysanthemum]

The DSM-4 had

• Asperger's Syndrome [AS] which was autism without any significant speech or cognitive delay, and
• [Kanner's] Autism which did have delays in one or both arenas.

When it came to practical therapy, Kanner's was informally divided into two sub-categories,

• High-Functioning Autism [HFA], for those who could dialogue with their therapist, and
• Low-Functioning Autism [LFA], for those who could not.

Part of the problem with that system was that no one could agree on the line where HFA ended and AS began.

DSM-5's severity levels addressed that. AFAIK, only one severity level is given in view of all of a person's support needs, not for their particular needs.

Many members, here, know the meaning of ASD1, ASD2 & ASD3, but when a therapist explains it to someone who is unfamiliar with these terms, they will say high-, mid- or low-functioning autism just for simplicity's sake.

See Autlanders, Thriving Outside of the Box: Autism Subtypes...

(Feel free to ask again, if that post doesn't clearly answer your question.)

Thank you. I thought "high-functioning autism" and "low-functioning autism" was based on whether one had an IQ above or below 70 and think that being able to dialogue with one's therapist through whatever means does not necessarily directly correlate to one's IQ level?

 

[Chrysanthemum]

DSM is the one used in the US. ICD is published by the WHO. I honestly have not checked the ICD yet, so I don’t know whether they have the same criteria for ASD or not.



I think, almost every autistic improves in his/her social skills and other aspects as they grow up. It’s not clear in the DSM if the diagnosis is “improved,” but a child diagnosed with level 3 ASD at 5 y/o would not develop the same “level” of social skills at 10 y/o as that another child with ASD-1 will develop at the same age; they will, throughout their life, require different amounts of support.


Yes. One of the main criteria is that daily functioning must be affected in some way or another. That’s what disorder in Autism Spectrum Disorder means. It has the same meaning in Major Depressive Disorder, Anxiety Disorder, etc.

Thank you for sharing.

I see your point that different children with ASD may require different amounts of support throughout their lives. But then the severity levels are somewhat confusing to me especially level 1 v.s. level 2 or level 2 v.s. level 3 and also because there are now 2 criterions (from what I have read in the past there were 3 for Autistic Disorder and 2 for Asperger's, there was also PDD-NOS that I think was considered an ASD) that need to be met for ASD and the level of support needed in each one may differ. I am not a professional but I still am not convinced that it is really possible to predict a young child's level of social skills in the future (assuming no unexpected accidents etc) but even if 2 children develop the same level of social skills one may take longer to do so and/or require more support to do so (though what is meant by "social skills" may also be important like I feel that it is actually possible for someone with ASD and less developed spoken (or written) language to have somewhat better social skills than someone with ASD and more developed spoken (or written) language), though I gave a hypothetical 3 year old not a 5 year old as an example and I read that ASD could definitely be diagnosed from age 2 (which to me sounds very young to assign a "severity level"). Though at the end of the day to me it's not so much what the severity level that was assigned that is important but more that people are given the appropriate amount and type of support that they need.

 

[Crossbreed]

By "functioning level" do you mean in social interaction, daily living or intellectual functioning?

I mean their perception & thought processes. They view their world comparable to a neuro-typical child of their stated mental age and respond at the same level.

By mental age, I mean neuro-typical mental age. That is the standard used to diagnose all levels of ASD. IIUC, neuro-typical brains do not stop developing until 25yo. When neuro-diverse people (like autistics & gifted) are assessed, some or all of our levels do not conform to NT benchmarks. That is what is meant by "pervasive development disorder.*"

One can be mute and still function at otherwise [NT] age-appropriate levels. That is different than my two described children (and many like them) whose overall function is consistent with the NT age-levels stated. That level of dysfunction is the consequence of their co-morbid conditions. Healthy ASD1 does not exhibit such severe delays.

(Do not confuse this with "able-ism." There would be no diagnosis, if there was no standard to gauge it against.)

*Among the gifted, it is known as "asynchronous development."

 

[Chrysanthemum]

I mean their perception & thought processes. They view their world comparable to a neuro-typical child of their stated mental age and respond at the same level.

By mental age, I mean neuro-typical mental age. That is the standard used to diagnose all levels of ASD. IIUC, neuro-typical brains do not stop developing until 25yo. When neuro-diverse people (like autistics & gifted) are assessed, some or all of our levels do not conform to NT benchmarks. That is what is meant by "pervasive development disorder.*"

One can be mute and still function at otherwise [NT] age-appropriate levels. That is different than my two described children (and many like them) whose overall function is consistent with the NT age-levels stated. That level of dysfunction is the consequence of their co-morbid conditions. Healthy ASD1 does not exhibit such severe delays.

(Do not confuse this with "able-ism." There would be no diagnosis, if there was no standard to gauge it against.)

*Among the gifted, it is known as "asynchronous development."

Thank you, I wasn't sure whether you were referring to mental age as in socially or as in intellectually?

"By mental age, I mean neuro-typical mental age. That is the standard used to diagnose all levels of ASD." Thank you for explaining. If you put it that way I might assume you mean socially (though perhaps you mean intellectual functioning i.e. IQ) since in my understanding ASD is primarily a condition involving social challenges or differences and repetitive and/or restricted behavior, I do understand that ASD can co-exist with intellectual disability but to my understanding ASD in itself even if classed as moderate to severe in itself is not a disorder of intellectual functioning (i.e. IQ below 70 and difficulties in adaptive functioning) though perhaps people with more severe levels of ASD are more likely to have intellectual disability (I read that in people with intellectual disability for ASD to be diagnosed social functioning should be below what would expected for their intellectual functioning Diagnostic Criteria | Autism Spectrum Disorder (ASD) | NCBDDD | CDC ... states from the DSM-V one of the criteria for ASD: "
"

1. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level."

Also I thought the severity levels were just used to describe how much support a person needs due to their ASD not as an indicator of their intellectual functioning (unless you mean mental age as in socially) and in any case from the CDC link it seems that professionals making a diagnosis using the DSM-V are required to specify if the ASD is co-morbid with a language impairment and/or intellectual impairment? Meaning that they wouldn't need to use severity levels to indicate that though I could imagine maybe that could influence their social-communication and social-interaction influencing the severity level given?

Thank you for your explanation.

 

[Crossbreed]

Also I thought the severity levels were just used to describe how much support a person needs due to their ASD not as an indicator of their intellectual functioning (unless you mean mental age as in socially) and in any case from the CDC link it seems that professionals making a diagnosis using the DSM-V are required to specify if the ASD is co-morbid with a language impairment and/or intellectual impairment? Meaning that they wouldn't need to use severity levels to indicate that though I could imagine maybe that could influence their social-communication and social-interaction influencing the severity level given?

Autism is considered a "Pervasive Development Disorder."

Lack of social instinct is seen across the spectrum. By itself, it is PDD in its simplest form; ASD1. If the person is physically healthy, other traits may fail to develop in a timely fashion like speech, cognition, executive function or, in the case of my children, globally.

Severity levels are based on total need. Somebody who has failed to develop speech, but is nearly age-appropriate in every other way might be ASD1. Somebody who has a high IQ but little to no executive function might be more ASD2. Usually, ASD3 is affected more globally. (ASD2/3 severity is due to more severe co-morbid conditions.)

[NT] Executive Function Development​

(When "executive function" is tested, it returns an NT age-related score.)