Fein, D., Dixon, P., Paul, J. and H. Levin (2005). Brief report: Pervasive Developmental Disorder can evolve into ADHD: case illustrations. Journal of Autism and Developmental Disorders. 35 (4): 525-534.

This article purports that, over time and with intensive behavioral therapy, children who have been diagnosed with Autistic Disorder or Pervasive Developmental Disorder-Not Otherwise Specified can evolve to a point at which they clinically meet the criteria not for any diagnosis on the Autism Spectrum, but for Attention Deficit-Hyperactivity Disorder. The authors present three detailed case studies, and eight additional profiles of children in less detail, as examples of this phenomenon. The article draws attention to the frequent overlap and many similarities between pervasive developmental disorders and ADHD, as well as the marked improvements that children with Autism can make with the interventions available today, particularly when diagnosed early. However, there are inherent flaws in the central concept, and in the supporting evidence presented.

Fein, et al claim that the children in the study who were initially diagnosed with PDD were in fact "prototypical cases of PDD." It is unclear, though, what a prototypical case would be for a disorder which has only a paragraph-long description in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders IV - a paragraph that does not describe even one specific symptom necessary for its diagnosis. Fein, et al do not name a specific measure that they use to diagnose Autism Spectrum Disorders, such as Lord, et al's Autism Diagnostic Observation Scale.

The article does not mention Asperger Syndrome once - discussing classic Autism and PDD as if they are the only two diagnostic options on the Autism Spectrum - though the authors themselves observed some form of poor social skills (perhaps the definitive AS trait) in all but two of the children they believe to no longer have a PDD. (Of the remaining two children, one had perseverative interests - another hallmark characteristic of AS - and the other still had some form of language delay. Even if there were absolutely no remaining social skills challenges in this case, a language impairment is still a significant symptom for which ADHD alone would not account.) Many of these children sound more like they have Asperger Syndrome - and in some cases, co-occurring AS and ADHD - than ADHD alone.

However, most of the children in the case studies initially received their Autism/PDD diagnoses because of language or intellectual delay, and of course current DSM-IV criteria preclude a diagnosis of AS for any individual with such delays in their history. This is why a number of high-profile individuals who had childhood autism and have gone on the lead completely independent lives - like Temple Grandin, Stephen Shore, and Donna Williams - are still classified as Autistic. And in spite of their tremendous developmental gains, these individuals still have significant social issues - and because those issues are so complex, more solid evidence than Fein, et al's non-quantifiable and often vague observations of their participants' outcomes, collected over a longer portion of their lifespans, may be in order to substantiate a claim of Autistic symptoms completely subsiding. Both Autistic Disorder and Asperger Disorder are considered to be lifelong, ongoing conditions, and in fact childhood history is typically a necessary component of adult diagnosis. Many of the changes the authors observed - improved eye contact, increased reciprocal play - are skills that can be taught, without the underlying conditions going away.

The broad range of potential outcomes for individuals on the Spectrum who appear to be very low functioning in childhood exposes serious flaws in the practice of classifying adults based on how they presented as toddlers. In addition, the distinctions between Autism, AS, and PDD are not as clear - or as clearly understood by different diagnosticians - as they should be. However, current psychological and medical consensus does not allow for the clinical "un-diagnosing" of one of these pervasive conditions if the initial diagnosis is accepted as having been valid at the time it was made.

- John Cavanagh

Asperger Foundation International
501 Madison Avenue, 18th Floor
New York, NY 10022
Phone: 212-371-7755
www.aspfi.org