For healthcare professionals in the United States and globally, the American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) serves as the primary guide for diagnosing mental health conditions. The DSM is a comprehensive resource that provides standardized criteria to help ensure accurate and consistent diagnoses.
In 2013, the APA published the fifth edition, DSM-5, which outlined specific Autism Diagnosis Criteria. These criteria emphasize that an autism spectrum disorder (ASD) diagnosis requires demonstrating persistent challenges in social communication and social interaction across various situations. These challenges are evident in difficulties with social-emotional reciprocity, nonverbal communication used for social interaction, and the development, maintenance, and understanding of relationships.
In 2022, the APA issued the DSM-5-TR, a text revision to the DSM-5. This revision aimed to clarify the autism diagnosis criteria, changing the phrase “manifested by the following” to “as manifested by all of the following” to reinforce the intended comprehensiveness and precision of the diagnostic requirements.
DSM-5 Diagnostic Criteria for Autism Spectrum Disorder: A Detailed Breakdown
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by all of the following, currently or by history (examples are illustrative, not exhaustive, see text):
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Deficits in social-emotional reciprocity: This criterion covers a range of difficulties in the give-and-take of social interactions. For instance, this can include challenges in initiating or responding to social interactions, struggling with back-and-forth conversations, a reduced sharing of interests or emotions, or difficulties with typical social approach. An example might be a child who doesn’t readily engage in conversational games or share their excitement about a toy with others.
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Deficits in nonverbal communicative behaviors used for social interaction: This involves challenges with nonverbal communication, such as eye contact, body language, gestures, and facial expressions. Difficulties can range from poorly integrated verbal and nonverbal communication to a lack of facial expression or understanding gestures. For example, someone might struggle to maintain eye contact during conversations or use gestures to emphasize points while speaking.
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Deficits in developing, maintaining, and understanding relationships: This criterion focuses on the difficulties in forming and keeping relationships. This can manifest as problems adjusting behavior in different social situations, difficulties in sharing imaginative play or making friends, or a lack of interest in peers altogether. An example could be a teenager who struggles to understand social cues for making friends or adjusting their behavior in group settings versus one-on-one interactions.
Specify current severity: The DSM-5 requires clinicians to specify the current severity of ASD, which is based on the level of support needed due to social communication impairments and restricted repetitive behaviors.
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):
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Stereotyped or repetitive motor movements, use of objects, or speech: This includes behaviors like repetitive movements (e.g., hand-flapping, rocking), the repetitive use of objects (e.g., lining up toys, spinning objects), or repetitive speech (e.g., echolalia, using idiosyncratic phrases). For instance, a child might repeatedly flap their hands when excited or line up their toys in a specific order instead of playing with them in a typical way.
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Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior: This encompasses distress at small changes, difficulties with transitions, rigid thinking patterns, and ritualistic behaviors. An example could be a child becoming highly distressed if their daily routine is altered or needing to eat the same food for breakfast every day.
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Highly restricted, fixated interests that are abnormal in intensity or focus: This involves having intense, fixated interests that are unusual in their focus or intensity. This might include a strong attachment to unusual objects or excessively narrow or perseverative interests. For example, someone might develop an intense and all-consuming interest in vacuum cleaners or specific types of maps.
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Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment: This criterion includes being overly sensitive or under-sensitive to sensory input. This could involve apparent indifference to pain or temperature, adverse responses to specific sounds or textures, or excessive touching or smelling of objects. For example, a person might be extremely bothered by specific textures of clothing or be fascinated by lights and movements to an unusual degree.
Specify current severity: Similar to Criterion A, severity is also specified here based on the level of support needed for restricted, repetitive behaviors.
C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life).
This criterion highlights that the symptoms of autism must be present from early childhood, although they may not become fully apparent until later when social expectations increase or when individuals learn to mask their difficulties.
D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
The symptoms must significantly impact the individual’s daily life, affecting social interactions, work, school, or other crucial areas of functioning. This criterion ensures that the diagnosis is applied to those whose difficulties are causing real-world problems.
E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.
This criterion addresses the relationship between autism and intellectual disability. While both conditions can co-occur, the social communication deficits in autism must be more pronounced than what would be expected for someone’s general developmental level if intellectual disability is also present.
Note: The DSM-5 also clarifies that individuals previously diagnosed with DSM-IV conditions like Autistic Disorder, Asperger’s Disorder, or Pervasive Developmental Disorder-Not Otherwise Specified should now be diagnosed with Autism Spectrum Disorder. Furthermore, those with marked social communication deficits who do not fully meet the criteria for ASD should be evaluated for Social (Pragmatic) Communication Disorder.
Specify if: The DSM-5 allows for further specification to provide a more detailed clinical picture, including:
- With or without accompanying intellectual impairment
- With or without accompanying language impairment
- Associated with a known medical or genetic condition or environmental factor
- Associated with another neurodevelopmental, mental, or behavioral disorder
- With catatonia
Social (Pragmatic) Communication Disorder DSM-5 Diagnostic Criteria
The DSM-5 also includes criteria for Social (Pragmatic) Communication Disorder, a separate condition related to difficulties in social communication. The criteria are:
A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following:
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Deficits in using communication for social purposes: This involves difficulties using language appropriately in social contexts, such as greeting, sharing information, or asking questions in a manner that is suitable for the situation. For example, someone might struggle to initiate greetings or ask irrelevant questions in conversations.
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Impairment of the ability to change communication to match context or the needs of the listener: This refers to difficulties adapting communication style to different social settings or listeners. This could include speaking too formally in informal settings or not adjusting communication when speaking to a child versus an adult.
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Difficulties following rules for conversation and storytelling: This encompasses challenges in understanding and following social rules of communication, like taking turns in conversation, knowing when and how to rephrase when misunderstood, and using verbal and nonverbal cues to regulate interaction. An example is interrupting frequently or struggling to understand turn-taking in conversations.
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Difficulties understanding what is not explicitly stated and nonliteral or ambiguous meanings of language: This involves challenges in understanding implied meanings, inferences, humor, metaphors, and idioms. For instance, someone might take figurative language literally or miss sarcasm in conversations.
B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination.
Similar to ASD, these communication difficulties must cause significant functional limitations in various aspects of life.
C. The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities).
The symptoms must emerge in early childhood, although they might become more noticeable as social communication demands increase.
D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains or word structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder.
This criterion ensures that the communication difficulties are not better explained by other conditions, including ASD.
Conclusion
The DSM-5 autism diagnosis criteria provide a standardized framework for diagnosing autism spectrum disorder and related social communication disorders. Understanding these criteria is crucial for clinicians, educators, individuals, and families seeking to understand autism and access appropriate support and interventions. The DSM-5-TR revision further clarifies these criteria, emphasizing the need for comprehensive assessment across multiple domains of social communication and behavior for an accurate diagnosis.
For further information and support, resources like the Autism Speaks Autism Response Team can offer valuable assistance.
