An Interview with Dr. Allen Frances, M.D.: What happened to Autism? What Happened to Pluto?

Nov 4, 2013 by

Michael F. Shaughnessy –

1) Dr. Frances- what do you see as the major changes from DSM-IV to DSM-V in terms of Autism or Pervasive Developmental delay?

DSM 5 has condensed into one autism spectrum disorder what had previously been two separate and quite different disorders-classic autism and the much less severely impairing Asperger’s Disorder. And it has introduced a new criteria set for defining autism.

2) Are these changes positive or negative? Both. The argument for collapsing is the existence of presentations at the boundary between the two previous categories that are difficult to put into either. The argument against is a significant loss of precision and increased stigma for people currently diagnosed as having Asperger’s.

And, more on the clearly negative side, the new criteria set is so imprecisely written that it will be impossible to interpret reliably. Different evaluators will now have very little agreement in diagnosing autism.

3) How will the changes affect the rates of autism?

The rate of autism has exploded during the past 20 years and studies suggest that it is now very much over diagnosed. At least in part, the ‘epidemic’ results from loose diagnosis occasioned by the fact that receiving the diagnosis qualifies someone for enhanced school and mental health services.

The original drafts of the DSM 5 criteria set were worded in a way that would have markedly reduced the diagnosis of autism. Responding to advocacy groups understandably concerned that this would lead to reduced services, DSM changed its wording at the last minute- but in a careless way that now makes the definition impossible to interpret.

4) What do you see as the implications of these changes?

The DSM 5 definition is essentially useless- written so vaguely that it can’t possibly be diagnosed with adequate reliability.

5) Are there specific tests for autism, or is it based solely on behavioral observations and history ?

There are no biological tests for autism and my guess is that it will be many years before we understand it well enough to have one. In the meantime, we should be humble in using the diagnosis; be aware of its limitations in administrative decisions, clinical practice, and research; try to avoid its overuse; and provide educational services based on an evaluation of each individual’s need, not on an inherently unreliable diagnosis that was developed for clinical, not educational, purposes.

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