Cognitive disorders are impairments to cognitive function (mental processes) to a degree where normal functioning is not possible without treatment. The question of whether autism spectrum disorders fit in this category will be considered in this article.
Many in the autism community feel offended by the use of the word “disorder”. For others it remains important as the word’s definition inevitably means autism is taken seriously by the medical community.
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So when examining the question of whether autism is a cognitive disorder, the word disorder is referred to in its traditional medical sense; to facilitate references to definitions in medical journals and important scientific studies. However, this in no way disregards the opinion of those who advocate for less loaded terms for autism like autism spectrum conditions.
In this article, autism spectrum disorder (ASD) will be examined to establish whether the condition qualifies as a cognitive disorder. Autism as it is defined by the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) will be the starting point.
Relevant cognitive theories will then be discussed to determine whether they predict symptoms associated with autism. Lastly, the definition of cognitive disorders will be examined to determine whether autism qualifies as a cognitive disorder or not.
What is autism?
Most experts classify autism as a neurodevelopmental disorder. This term is very broad and in the words of Sherr (2016): “In the overlap between the fields of neurology, psychiatry, and pediatrics, it may be hard to find a term with as much generality as neurodevelopmental disorders (NDD).”
Many will also use words like “complex”, “spectrum disorder” and “nonprogressive” to describe autism. Autism is a complex condition with a spectrum that includes many different symptoms ranging in severity and presenting differently for most individuals.
To some, the DSM-5 represents a strict and scientific way of diagnosing autism. To others the criteria is too strict; not everyone was happy about the single umbrella disorder introduced by the DSM-5.
The Diagnostic and Statistical Manual of Mental Disorders (4th ed, rev.) or DSM-4 had four separate diagnoses which were consolidated in the DSM-5’s diagnosis of ASD. These were: autistic disorder, asperger’s disorder, childhood disintegrative disorder, and the catch-all diagnosis of pervasive developmental disorder not otherwise specified (PDD-NOS). Many in the autistic community felt these separate diagnoses allowed more flexibility when diagnosing autism; therefore borderline or threshold cases did not fall through the cracks.
The DSM-5’s criteria of autism spectrum disorders centres around the following two areas:
- Persistent social communication difficulties
- Restricted, repetitive behaviours or interests, this area includes sensory challenges
The symptoms should be present from an early age, and should cause significant difficulties in important areas of functioning (the DSM-5 criteria for autism spectrum disorders is detailed, the journal should be consulted for the exact criteria and specific examples of symptoms).
When looking at these two core areas of symptoms or deficits, it may be helpful to look at some cognitive theories like the theory of mind, executive function, and central coherence theory to determine whether autism can be classified as a cognitive disorder.
Theory of mind
The theory of mind is a skill or cognitive ability to make inferences about other people’s mental states; it typically develops in children between the ages of three and five. This ability enables us to utilize our understanding of others’ beliefs, intentions and desires to predict behavior. Many studies have found the theory of mind to be impaired in individuals with ASD.
To test this theory, the Sally-Anne test is often used due to its simplicity. The Sally-Anne test is a false belief test that determines whether a child is able to attribute false beliefs to others. The test was first implemented by Baron-Cohen, Leslie and Frith (Baron-Cohen et al., 1985) and it involves two fictional characters: Sally and Anne.
Sally leaves her ball in a basket and leaves the scene. Upon her departure Anne moves the ball from the basket into a box or closet. In this experiment children are then required to predict where Sally will look for the ball when she comes back. Neurotypical four-year-olds usually get this right by attributing the false belief to Sally. Very young children and those on the spectrum often fail the test.
The cognitive capacity to infer the mental states of others’ may be vital to the development of social communication. An autistic child who struggles with this social-cognitive skill will have challenges with social communication. The deficits displayed in theory of mind by those with ASD, could possibly make a case for considering autism as a cognitive disorder.
Executive function
Executive function is a cognitive process that helps us to set goals, organize and plan, focus our attention, and ultimately get things done. Executive functioning involves complex cognitive processes like working memory, problem solving, and flexible thinking—investigating its dysfunction in autistic individuals is even more complex.
The relationship between executive dysfunction and behavioral symptoms in autism is of interest to many researchers (Shiri et al., 2020). Studies found a link between executive function and both social and non-social symptoms associated with ASD, but more research is needed to pinpoint the exact relationship (Van Eylen et al., 2015).
Central coherence
Uta Frith proposed the Weak Central Coherence Theory in 1989, this theory encapsulates many of the everyday struggles faced by people with autism. It refers to a cognitive style that may cause an individual to focus on details rather than the global form; in other words the inability to see “the big picture”. Some believe this focus on details—at the expense of finding meaning—may be at the bottom of some ASD symptoms (like insistence on sameness).
While cognitive theories are not unique to those with ASD, they can help us to understand the challenges faced by many autistic people. Cognitive explanations of autism can link together brain and behavior, with cognition at the centre (Frith, 2012).
What is a cognitive disorder?
In a review of cognitive deficits, the authors (Dhakal & Bobrin, 2020) define cognitive disorders as any disorder that significantly impairs the cognitive functions of an individual; so that normal functioning is not possible without treatment. To illustrate the definition, the authors use Alzheimer’s disease as the most well-known cognitive impairment.
This definition goes some length to explain why people label ASD as a neurodevelopmental disorder, rather than a cognitive disorder. According to Green et al. (1995) autism is a syndrome defined mostly in behavioral terms, but it is associated with a wide range of cognitive deficits.
There seems to be disagreement among researchers when it comes to supremacy of cognitive versus behavioral symptoms. Many researchers do feel that comprehending the cognitive processes in autism is a prerequisite to understanding how the condition develops.
In conclusion
While there is agreement that autism is a neurodevelopmental disorder, as it doesn’t quite fit the definition of a cognitive disorder, the cognitive element of ASD is a crucial part to understanding the condition. Studies (Brunsdon et al., 2015) suggest that multiple cognitive atypicalities are characteristic of ASD. However, these and other studies also admit that autism research has some way to go to better understand the exact cognitive features of ASD.
References:
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., rev.). Washington DC: Author. (Pg. 84)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.
Baron-Cohen, S., Leslie, A. M., & Frith, U. (1985). Does the autistic child have a “theory of mind”?.Cognition, 21(1), 37–46. https://doi.org/10.1016/0010-0277(85)90022-8
Brunsdon, V. E., Colvert, E., Ames, C., Garnett, T., Gillan, N., Hallett, V., Lietz, S., Woodhouse, E., Bolton, P., & Happé, F. (2015). Exploring the cognitive features in children with autism spectrum disorder, their co-twins, and typically developing children within a population-based sample. Journal of child psychology and psychiatry, and allied disciplines, 56(8), 893–902. https://doi.org/10.1111/jcpp.12362
Dhakal, A., & Bobrin, B. D. (2020). Cognitive Deficits. In StatPearls. StatPearls Publishing.
Frith, Uta. (2012). Why we need cognitive explanations of autism. Quarterly journal of experimental psychology (2006). 65. 2073-92. 10.1080/17470218.2012.697178.
Frith, U. (1989). Autism: Explaining the enigma. Oxford: Blackwell.
Sherr, E. H. (2016). Chapter 36 – Neurodevelopmental Disorders, Causes, and Consequences. In Lehner, T., Miller, B. L. & State, M.W (Eds.). Genomics, Circuits, and Pathways in Clinical Neuropsychiatry (pp. 587-599) Academic Press,
https://doi.org/10.1016/B978-0-12-800105-9.00036-6.
Shiri V, Hoseyni S A, Pishyareh E, Nejati V, Emami M, et al. Is There any Correlation Between Executive Dysfunction and Behavioral Symptoms in Autistic Children? A Systematic Review, Arch Neurosci. 2018 ; 5(2):e64303. doi: 10.5812/archneurosci.64303.
Van Eylen, L., Boets, B., Steyaert, J., Wagemans, J., & Noens, I. (2015). Executive functioning in autism spectrum disorders: Influence of task and sample characteristics and relation to symptom severity. European Child & Adolescent Psychiatry, 24(11), 1399–1417. https://doi.org/10.1007/s00787-015-0689-1
