According to Tantam (2012), the Triad of Impairments, that comprises impairments in social interaction, social communication, and imagination, underpins the diagnosis of ASC. These impairments co-occur with rigid and repetitive patterns of interests and behaviours (Noens & van Berckelaer-Onnes, 2005). The triad is central to all diagnoses that together make up the autism spectrum (Attwood, 2007; Tantam, 2012).
What comprises the triad has evolved over time. It was first described by Wing and Gould (1979), as impairments in social interaction, social communication, and social imagination and creativity. Boucher (2017), explains in later publications, that Wing simply referred to the Triad as impairments in social interaction, communication, and imagination, while categorising specific behaviours under each element. However, Lord and Bishop (2010), defined the Triad as deficits or unusual behaviours within three domains: “reciprocal social interaction, communication, and restricted, repetitive interests and behaviours” (p. 4). Irrespective of these differences, the concept of the Triad of Impairments is central to “the construct of autism: impaired communication; impaired social skills; and a restricted and repetitive way of being-in-the-world” (Cashin & Barker, 2009, p. 189). Similar to the evolution of understandings regarding autism, an understanding concerning the Triad has also advanced.
Evolution of the Diagnostic Criteria
Clinical understanding of ASC has grown substantively since the time of Kanner and Asperger. Despite that, Cashin and Barker (2009), stress that the Triad of Impairments has continued to be defined purely by its behavioural manifestations. They suggest, that while original interpretations of the Triad were particularly effective in identifying and monitoring the progress of those on the autism spectrum, they were transitional steps that required reconsideration in light of recent diagnostic information. Cashin and Barker (2009), propose an alternative view: the location of the Triad at the level of cognitive processing. Cognitive processing is constant and universal unlike the variable and inconsistent nature of behavioural manifestations. Thus, according to Cashin and Barker (2009), the Triad of Impairment needs to be reconsidered as impairments in visual processing, abstract thinking, and theory of mind, rather than as impairments in linguistic processing, abstraction, and lack of theory of mind. According to Cashin and Barker (2009):
Incorporating recognition of the cognitive processing deficits into diagnostic schedules may allow us to move beyond observation of behaviour, that is variable and context specific, to more exacting testing designed in such a way to eliminate the confounding variable of testability (p. 193).
The recent changes in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013), have attempted to unify current schools of thought. However, according to some, these changes have only served to create further disagreement (Linton, Krcek, Sensui, & Spillers, 2014; Smith et al., 2015). The DSM-5 defines three levels of increasing severity of ASD, from (1) “requiring support” to (2) “requiring substantial support”, and finally to (3) “requiring very substantial support” (American Psychiatric Association, 2013). The three levels have replaced the previous diagnostic subcategories: PDD-NOS, HFA, AS and AD, which have all been subsumed into the single diagnosis for ASD. At the time of writing Asperger’s Syndrome meets the criteria of level one for ASD.
The central argument around the DSM-5 criteria is in regard to the abolition of the diagnostic subcategories and whether people with AS or people with an IQ greater than 70, will still meet criteria for a diagnosis of an ASC. The result, for some people, is that they may not qualify for the same level of support and services that they were receiving (Smith, et al., 2015). Further, Posar, Resca and Visconti, (2015) state that the current DSM approach (three severity levels) does not take into account specific differences within the severity levels to allow the division of people into sufficiently homogeneous groups. In addition, potential gender bias (Linton et al., 2014), and de-emphasising the significance of language abilities that are not employed specifically in social communication (Posar et al., 2015), are added concerns resulting from DSM-5 ASD criteria.
Further to debates surrounding the DSM, misperceptions, misinterpretations and confusion can arise when different countries follow different diagnostic guidelines. Awareness of autism, differences in case ascertainment, treatment infrastructures, behavioural expectations, symptom presentation, symptom interpretation, reaching an accurate diagnosis, accessing therapy, and acquiring epidemiological data can differ from nation to nation (Fein, 2015; Onaolapo & Onaolapo, 2017). Additional to the DSM, the other main official diagnostic source is the International Classification of Diseases (ICD) (published by the World Health Organisation). The DSM is favoured in the USA and the ICD is commonly used in Europe; however, DSM criteria are also widely used in Europe. Interestingly, both systems are also used in many other parts of the world. While there are similarities between the two, there are also differences (Gaebel, 2015). Gaining a diagnosis is still subject to a clinician’s level of education, autism awareness, and their understanding. Therefore, at the time of writing, accurate global prevalence rates are unknown and acquiring diagnosis is quite a challenging task for many, especially once reaching adulthood; more so for women.
Dr. Bronwyn Wilson
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (Fifth ed.). Arlington, VA: APA.
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Attwood, T. (2007). The complete guide to Asperger’s Syndrome. London and Philadelphia: Jessica Kingsley Publishers.
Boucher, J. (2017). A framework for explaining autism In Autism spectrum disorder: Characteristics, causes and practical issues (2nd ed., pp. 90-99). London: Sage Publications Ltd.
Cashin, A., & Barker, P. (2009). The triad of impairment in autism revisited. Journal of Child and Adolescent Psychiatric Nursing, 22(4), 189-193. Retrieved from http://search.proquest.com.ezproxy.ecu.edu.au/docview/232965844/fulltextPDF/3EE30FDF2AD94369PQ/1?accountid=10675#
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Smith, I. C., Reichow, B., & Volkmar, F. R. (2015). The effects of DSM-5 criteria on number of individuals diagnosed with Autism Spectrum Disorder: A systematic review. Journal of Autism and Developmental Disorders, 45(8), 2541-2552. doi:10.1007/s10803-015-2423-8
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