How did autism become the latest fad disorder?

Cecil's Columns/Staff Reports
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Professional

It’s an interesting hypothesis, but it doesn’t really address the “Nature/Nurture” debate. On the one hand, if there is a genetic component, then mating between two carriers will accentuate it. On the other hand, being an Aspie is hip in some circles, skewing the results. A not-insubstantial subset of the population of Silicon Valley already thinks they are the RL incarnations of Sheldon and Amy from The Big Bang Theory, see that as normal, and are raising their kids that way. Much like how a subset of Jews values education, so their sons become doctors, while a subset of rural Americans values the ability to catch catfish with their bare hands, so their sons become reality TV stars–are the children of self-styled Aspies acting that way to please mommy and daddy?

And on yet another hand, the hypothesis’ leading proponent is Sasha Baron-Cohen’s cousin, so we cannot eliminate the possibility of wise-assery.

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First, the problem with the DSM. The DSM analyzes mental illnesses by symptoms. It would be like a doctor analyzing whether you have allergies by you having a running nose and sneezing. It could be allergies, it could be a cold. It could be because the doctor is wearing too much cologne. If a doctor suspects allergies, they do medical tests and confirm their diagnosis. The DSM has no medical tests. It’s just symptoms.

Now, why labels. Labels are helpful. This is especially true if you’re a parent, and your kid just isn’t doing what other kids their age do. Maybe your kid can’t sit in class. Maybe your kid has problems making friends. Maybe your kid isn’t sociable and seems to gravitate to strange bits of information.

In the old days, the kid would be simply considered a bad kid. He doesn’t pay attention. He’s out of control. And, it’s your fault because if you were good parents, your kid wouldn’t behave like this. It was okay in the old days for other kids to make fun of your kid. It’ll teach them to behave. Teachers could call your kid lazy because their grades don’t reflect their intelligence level, and it’s your fault because you are lousy parents. If the kid drops out of school it’s because they were a bad apple to begin with.

Remember in the old days when doctors said that schizophrenia was caused by cold parents and a domineering mother. As one psychology professor once told me, that was absolutely cruel: “Your child has a disease we don’t understand, there’s no cure for, and it’s your fault!.”

Unless you have raised such a kid, you have a hard time understanding this. You have other kids who are absolutely normal. They do well. They have lots of friends. No one says "You have such good kids, you must be pretty good parents. They look at that one child and ask “What’s wrong with you? What did you do to make the kid behave like this?”

If you can say, my kid is ADHD or my kid is Aspergers, it’s different. It means that the school will [gasp] tailor their teaching to help your child and help your child. Maybe they won’t call them lazy because they aren’t able to read at the same level as the rest of the class. Maybe they’ll understand that if the child makes copying errors while attempting to copy stuff off the board, it’s not necessarily them being careless. Maybe they’ll pay attention and help your child compensate and learn to deal with their issues instead of belittling them.

You see why parents are quick to grab labels like ADHD and Aspergers? It makes the school work with the child instead of dismissing them as some sort of issue that they would like to go away. It makes teachers understand that your child isn’t being bad, but could be a rather good and intelligent kid who needs some guidance.

What parent wouldn’t want that for their child?

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Getting a diagnosis so your kid can get the help they need is a good thing. The catch is that, in order for it to work, the diagnosis has to be accurate. Sure, some of the help will be the sort of thing that will help anyone: Smaller class sizes, for instance, and more personalized interaction with teachers. Nothing wrong with that other than using up scarce resources. But some kinds of help will do nothing or actually be harmful, if misapplied. Kids with genuine ADHD, for instance, will be helped by stimulants such as Ritalin, but in a kid without ADHD but who’s misdiagnosed with it, Ritalin will make things worse, and in fact will actually produce some results similar to ADHD itself.

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dropzone the assortive mating hypothesis is predicated upon making the assumption that there is an actual increase in true autism, not diagnostic creep. This means kids who have a true disability, not who are just acting geeky because they are raised that way. Kids who develop language late and later don’t use language well, who are delayed with imaginary play (if ever using it), who have a real need for sameness and routine from early on and who may decompensate if such does not occur. Here’s his actual article proposing the hypothesis (I hope the link works) if you want to go beyond a pop culture treatment of the subject. A practical way of looking at it - there are genes that predispose to certain traits (like in Baron-Cohen’s parlance, “systematizing”) that have benefits in certain subjects and careers, a narrow focus of interests, good at rules-based subjects. Often people with these traits go into math or progamming based career paths. The downside to those traits is that the narrow focus of interests often travels with social awkwardness/shyness. In past generations the odds of two of those people meeting and having children together was fairly low; at least one needed to have some above average social acumen to bring the other one along. Now both are more likely working in the same sort of venue or more likely to be meeting in a narrow focus chat room or otherwise on-line where social skill importance is diminished; they are more likely to have kids together than in past years, and those kids are more likely to get a larger dose of those genes. A few of these genes may be of benefit; too many can cause significant disability. It is a speculative hypothesis to explain something that we do not know is true … but it is appealing nevertheless.

qazwart, no allergies do not require a medical test to confirm the diagnosis. Sometimes tests are done but the diagnosis is mostly made from the history. I also don’t need a test to diagnose influenza, or a URI, or conjunctivitis, or … the list goes on. I need a story and a set of symptoms. Tests are over-rated. That’s one of the most important things for any doctor in training to learn: history history history. There is usually no excuse for not being pretty sure about the diagnosis by the time you are done getting the history. Symptoms are not “just” symptoms … they are the key to most diagnoses with exam and select tests serving as support, not gold standards.

Agreed that labels are helpful and with Chronos that labels must be accurate to be helpful. But when presented with a young child whose hair is sandy and told that the child must be called one of “blonde” “brunette” or “redhead” … what do you do? What if the reality was that a blonde child is at risk for serious disability that early identification could help reduce, and that such help would only be available if you labelled the kid as “blonde”? You think that maybe a few more sandy haired kids might get the blonde label than before, more likely blonde than brunutte or readhead?

Such is the case with autism. We pediatricians now actively look for kids who demonstrate development that might be early autism because we know that getting them identified can make resources available that will help them if they are. We ask at 15 months about pointing and using non-verbal communication and imitation skills, at 18 months about emerging pretend play, some use formal tools like the M-CHAT. And when you look you find.

It’s been there all along, I am pretty sure of it. We were just better at ignoring the signs before. Afterall, why look for something that you can’t do anything about?

Point being that it is not just parents who are advocating for accurate labels in order to get their kids a share of the special help pie; it is pediatricians who are more highly motivated to find something because they now understand that identifying it early will make a major positive impact and that they have the ability to make that happen with a simple referral to the developmental team.

Another reason gravitate to labels is that we are magical thinkers. These parents know that something is “off” about their kids. Naming it validates that sense and we in our hearts still believe that naming something gives us power over it.

Chronos, btw actually stimulants will help kids without ADD focus better too. That’s one of the reasons they are abused by many college kids without ADD. (Most commonly by underperforming students who also abuse other substances who are hoping for a short-cut.)

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Which is why it’s an interesting working hypothesis that may lead to discovery of a genetic component, if that assumption is accurate.

That is where Apsberger’s is the odd man out, as you describe later. In symptoms (history! ;)) it has more in common with Obsessive/Compulsive Disorder than the other ASDs, and which plays into my own Grand Unified Insanity Theory. Which would work better if I had any credentials or training or knowledge and weren’t pulling it wholly out of my butt.

Link works, and I’ll read it when I’m more awake.

And it seems patently obvious to the casual observer. I’ve never been an either/or kinda guy, so I will not discount genetics while supporting an additional factor of “because they can get away with being obsessive jerks.” Intelligence isn’t needed for a kid to figure out how far he can push behavior that makes him happy before authorities start pushing back; dogs do it, too. If he has two parents who do not disapprove of, or even support, his behavior, be it programming or selling drugs, he will continue it.

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It seems pretty apparent that people are glomming onto ASDs as a fad. That’s just a factual observation.

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What people, and define “glomming”?

I’ll ignore, for the moment that “seems pretty apparent” does not equate to “factual observation.”

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As a parent of two children diagnosed with autism (AU) I have to disagree with this somewhat. It has been my experience that there is a “trend” within the medical profession itself to slap the AU label on any child who does not fit their idea of “normal”.

My son is without a doubt autistic. He had an intense series of evaluations and saw an entire team of specialists before he was diagnosed. Four years later, after the Autism “boom” I took my daughter in for an evaluation because her speech was slightly delayed. (We were seeking speech therapy services for her.) We walked out the door of the Developmental Pediatric Specialist’s office with an Autism diagnosis for her as well. This was after a brief question/answer session during which the pediatrician observed my daughter as she played with toys. The pediatrician cited “hair flipping” and “poor eye contact” as tell-tale AU signs. My daughter had long hair that kept getting in her eyes and was distracted by new toys. I called BS and had her evaluated by the same team who had worked with my son when he was younger. Their diagnosis? Speech delay, otherwise perfectly normal child.

And for those parents who DO try to self diagnose, that falls heavily back on the medical profession and government as well IMO. They shove it in your face from the minute your kid is born with questions and surveys and observations. It’s at every doctors visit, every well check, and every government subsidized program for children. They drill you so much on the warning signs that it makes people paranoid, making you see problems where they might not even exist.

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It’s also not the disgrace it once was to have a child with some kind of problem.

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History is a very useful and often frontline diagnostic method for illness, and it usually works pretty well. However, a lot goes into understanding the basis for the disease to understand how the symptoms work as a set, and how the treatment is effective. And sometimes the “history = diagnosis” approach doesn’t work. You may know it’s a URI, but the first round of antibiotics you give doesn’t work. To narrow it down, you need a better diagnosis, i.e. culture to see what it actually is (test).

Hell, I’m right now in the middle of a throat infection that knocked me on my ass. Went in almost immediately, got told

[QUOTE=my doctor]
It’s a throat infection of some sort. It’s probably a strep or strep-like infection, but could also be mononucleosis. In order to tell, I would need to culture it, and that takes three days. Meanwhile, we’d take the same course of action. If it’s bacterial like strep, the antibiotics will work. If it’s mono, the antibiotics won’t help. So I’ll give you antibiotics, and if you’re not doing better by Monday, come back and we’ll assess further.
[/QUOTE]

And he gave me a shot in the ass and a prescription, and it seems to be clearing it up pretty well (though I’m still a bit run ragged). In this case, the test wasn’t necessary because the course of action that was most likely was going to be the interim course anyway, and it seems to be working, so the diagnosis of bacterial infection is shown to be correct. But it wasn’t a sure bet.

The point for mental health disorders is there isn’t really an underlying biological underpinning that we understand. With allergies, you may be able to diagnose it is allergies just from history, but the biological mechanism of allergies is understood and the treatments are based upon that underpinning. With mental health issues, most don’t have a solid underpinning, they are just an amorphous collection of symptoms. That is the DSM, and that was already understood in changing from DSM-IV to DSM-V.

In fact, the National Institute of Mental Health (NIMH) has already announced that it is shifting research dollars away from trying to find the biological underpinnings of DSM defined conditions and toward finding the biological underpinnings of disease and then define the deseases and conditions based upon the research results. This is not an immediate thing, and the DSM is still the clinician’s best tool, but efforts are being made to look for a disease model based upon real biological markers rather than symptom clusters.

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No offense but your doctor as described is an idiot.

  1. Almost all our offices have Rapid Strep tests avaialble that can give a result in less than 5 minutes. They are not perfect tests but they are as good as cultures which are also not perfect.

  2. The test should be done when, by history and exam, strep is fairly likely. That is not every sore throat. A sore throat with cough and cold symptoms, only a low grade fever, and none of the classic strep signs like headache, nausea, belly ache … does not need a test and does not need treatment with antibiotics.

  3. Your point though about history and exam not being enough always is valid: even those histories and exams that are consistent with strep will very often not be and those do not need antibiotics either. Standard of care is clear: do not treat a sore throat with antibiotics without a positive test result, either a Rapid Strep or a culture. Do not do the test unless the history and exam suggests a fairly high probability that it is strep. In this case a test as support for the diagnosis is essential. Antibiotics used without good cause is the cause of lots of problems. Please note however, the test is used as support of the diagnosis. A positive strep test in the context of a story and exam that is inconsistent with strep has a good chance of being wrong; the person is likely just a carrier. The test is not the gold standard of the diagnosis.

  4. By mouth medicine, penicillin or amoxicillin, works just fine. No shot needed. Those who opt for a shot (sometimes used in kids who refuse by mouth medicine or who are vomiting) do not also need medicine by mouth.

No question that the understanding of the biological underpinnings of many mental health disorders is an emerging work in progress. There are few to no tests to use in that support of the diagnosis function. The exam is of little help. We are indeed left with history history history. But again, that is not an otherwise unheard of circumstance in medicine.