Intended for healthcare professionals

Rapid response to:

Clinical Review

Diagnosis of autism

BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7413.488 (Published 28 August 2003) Cite this as: BMJ 2003;327:488

Rapid Response:

"We're All on the Autistic Spectrum!"

Baird G, Cass H & Slonims V entitle their article "The Diagnosis
of Autism", yet the first three words in the first sentence of their first
paragraph are "Autistic Spectrum Disorders..." (BMJ 2003;327:488-493).

No further mention of "Autistic Spectrum" occurs until well into the
second page, where they acknowledge that "Many clinicians find that,
although the term 'Autistic Spectrum Disorder' does NOT appear in either
the DSM4 or the ICD10 (international classifications of disorders), it is
much more easily understood by parents and professionals than pervasive
developmental disorders..."

They go on to say that "the number of children diagnosed as having
autistic spectrum disorders (note the plural) is increasing". One of the
reasons for this is "the inclusion of children with disorders such as
ADHD, Tourette's Syndrome,and Tuberous Sclerosis as also having autistic
spectrum disorder" (page 489).

Their use of the diagnosis called "Autism" and the diagnosis called
"Autistic Spectrum Disorders" begins, I suggest, to produce some confusion
in the mind.

Then, they add BONE FIDE diagnoses, such as ADHD and Tourette's
Syndrome and Tuberous Sclerosis to the Autistic Spectrum. The confusion
in the mind increases now that Tuberous Sclerosis is an Autistic Spectrum
Disorder; and Tourette's Syndrome is an Autistic Spectrum Disorder; and
that the Attention Deficit Hyperactivity Disorder is an Autistic Spectrum
Disorder!

Maybe we should ask what outcomes indicate the success of therapeutic
and teaching interventions. This may help us to comprehend what is the
cardinal feature of Autism.

Baird G et al give a helpful Box 8 in which are listed a total of
five outcomes for measuring the success of treatment: Normal use of verbal
language; some use of verbal language for a range of purposes; some
functional use of language; ability to use an alternative system of
communication; the child's idiosyncratic communication is better
understood.

In each of these five successful outcomes for Autism, there is one
constant thread, namely, the abnormal use of language for communication.
I suggest that Autism is none other thatn the THE ABNORMAL USE OF LANGUAGE
FOR COMMUNICATION (as opposed to the delayed development of speech).

If that is what Autism is, then we do not need a spectrum any more
than we need an Asthmatic Spectrum or a Diabetic Spectrum or an Epileptic
Spectrum or an ADHD Spectrum.

The diagnosing clinician must decide either that the child has Autism
or he does not have Autism. If there is uncertainty, then it can be
reasonably said, "I am not sure at the moment whether your child has
autism or not, so I am going to run some more tests/get a second
opinion/wait a little longer when the clinical picture may become
clearer/etc".

The responsible clinician can justifiably give some idea of the
severity of the autism, that is the abnormal use of language for
communication, by saying that it is severe or it is moderate or it is
mild. This is what other clinicians say about ADHD, Asthma or Epilepsy
etc, so why not use this well-tried and well-trusted categorisation rather
than "Autistic Spectrum"?

I believe that the use of "Autistic Spectrum" (as opposed to a
straightforward diagnosis of Autism) is undisciplined thinking. Either a
child has the abnormal use of language for communication or he does not.
Don't leave him on the "Autistic Spectrum" when you cannot come to a clear
and definite diagnosis that he has Autism.

This undisciplined thinking is well illustrate by a psychologist, who
said that "We're all on the autistic spectrum!" Well now, if all or the
majority of people are on the "Autistic Spectrum", then it is no longer a
diagnosis. The diagnosis then becomes that which will distinguish those
who are not on the "Autistic Spectrum" from the normal position, which is
to be on the autistic spectrum.

The pinnacle of undisciplined thinking in regard to the "Autistic
Spectrum" is to create a diagnosis, place it on the "Autistic Spectrum",
and then declare that it differs from Autism by not having any abnormal
use of language for communication! I am referring to Asberger's Syndrome,
which must be the most useless (as far as treatment is concerned) and the
most perjorative diagnosis ever invented.

So, maybe Baird G et al would like to retract their statement that
the "Autistic Spectrum" includes ADHD, Tourette's Syndrome and Tuberous
Sclerosis. Or maybe, they would like to add Asthma, Diabetes and Epilepsy
to this wonderful, all-inclusive spectrum so that we can all have a good
laugh.

Competing interests:  
Specialist in the Diagnosis and Treatment of ADHD in children, adolescents and adults

Competing interests: No competing interests

03 September 2003
Dr P V Finn Cosgrove
Consultant All-Age Psychiatrist
Bristol Priority Clinic BA2 5YD