The Zero to Three/National Center for Clinical Infant Programs (NCCIP) (National Center for Clinical Infant Programs 1994) has developed an alter-native diagnostic taxonomy for emotional, behavioral, attachment, and devel-opmental disorders of childhood, which, as in DSM-IV, is multiaxial but, in contrast, places less emphasis on diagnostic labels in an attempt to avoid the problem of multiple diagnostic labels in any one individual. This diagnostic system addresses the manifestation of such disorders observed in infants and very young children up to age 4 years. It is not intended to replace existing taxon-omies as described in the nosology of ICD-10 and DSM-IV-TR, but to sup-plement and, by providing alternative conceptualizations, encourage an evolving heuristic of childhood mental disorders.
This system is designed around five axes: Axis I reflects the most promi-nent features of the disorder, and diagnostic labels are replaced by seven diag-nostic categories; Axis II describes relationship problems between the infant and his or her primary caregiver; Axis III includes medical conditions not
nec-10 Clinical Manual for the Treatment of Autism
Table 1–1. DSM-IV diagnostic criteria for autistic disorder A. A total of six (or more) items from (1), (2), and (3), with at least two from (1),
and one each from (2) and (3):
(1) qualitative impairment in social interaction, as manifested by at least two of the following:
(a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
(b) failure to develop peer relationships appropriate to developmental level (c) a lack of spontaneous seeking to share enjoyment, interests, or
achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
(d) lack of social or emotional reciprocity
(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
(3) restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
(a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus (b) apparently inflexible adherence to specific, nonfunctional routines or
rituals
(c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements) (d) persistent preoccupation with parts of objects
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.
C. The disturbance is not better accounted for by Rett’s disorder or childhood disintegrative disorder.
Source. Reprinted with permission from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric As-sociation, 2000. Copyright 2000, American Psychiatric Association. Used with permission.
Clinical Diagnosis of Autism 11
essarily related to the Axis I presentation and disorders included in other di-agnostic systems; Axis IV includes psychosocial stressors; and Axis V includes the infant’s functional and emotional developmental level according to specified criteria.
In the absence of strong empirical or scientific support for contemporary conceptualizations of childhood emotional and behavioral disorders, these Table 1–2. DSM-IV diagnostic criteria for Asperger’s disorder A. Qualitative impairment in social interaction, as manifested by at least two of
the following:
(1) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
(2) failure to develop peer relationships appropriate to developmental level (3) a lack of spontaneous seeking to share enjoyment, interests, or
achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
(4) lack of social or emotional reciprocity
B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
(1) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
(2) apparently inflexible adherence to specific, nonfunctional routines or rituals (3) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping
or twisting, or complex whole-body movements) (4) persistent preoccupation with parts of objects
C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.
D. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years).
E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.
F. Criteria are not met for another specific pervasive developmental disorder or schizophrenia.
Source. Reprinted with permission from American Psychiatric Association: Diagnostic and Statis-tical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychi-atric Association, 2000. Copyright 2000, American PsychiPsychi-atric Association. Used with permission.
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criteria are based on expert consensus and are in this respect similar to other nosological systems. In contrast, however, there are two major differences in the approach employed. First, the NCCIP system utilizes, at least in the case of autism, a very different set of diagnostic conceptualizations without a firm empirical basis. Second, unlike DSM-IV-TR and ICD-10, this system also focuses on the relevance of the interaction between an infant and his or her caregiver.
Although attractive in its novel approach, the NNCCIP system has a num-ber of difficulties. First, stress is known to be an important etiological factor that precedes many emotional and behavioral disorders or, at least, precedes their onset or acute manifestation. Therefore, giving primacy to it may be an inap-propriate simplification and may result in failure to identify important inter-individual pathological differences. Second, dismissing preexisting syndromal constructs fails to recognize that, although they are born from heuristic and de-scriptive methods, their continuing usage over the years derives in part from the supporting empirical and scientific evidence, in particular the etiological sig-nificance of conceptualizing and classifying them in this way. Third, treat-ments have been designed and their usefulness empirically established around existing taxonomies; it would therefore be difficult to argue the case for dis-missing any system unless the alternative had equal or better etiological and treatment implications.
Table 1–3. DSM-IV diagnostic criteria for pervasive developmental disorder not otherwise specified (including atypical autism) This category should be used when there is a severe and pervasive impairment in the development of reciprocal social interaction associated with impairment in either verbal or nonverbal communication skills or with the presence of stereotyped behavior, interests, and activities, but the criteria are not met for a specific pervasive developmental disorder, schizophrenia, schizotypal personality disorder, or avoidant personality disorder. For example, this category includes “atypical autism”—presentations that do not meet the criteria for autistic disorder because of late age at onset, atypical symptomatology, or subthreshold symptomatology, or all of these.
Source. Reprinted with permission from American Psychiatric Association: Diagnostic and Statis-tical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychi-atric Association, 2000. Copyright 2000, American PsychiPsychi-atric Association. Used with permission.
Clinical Diagnosis of Autism 13