The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), provided a detailed framework for diagnosing autistic disorder, often referred to as autism. Although superseded by the DSM-5, understanding the DSM-IV criteria remains valuable for historical context and for interpreting older diagnoses. This article breaks down the DSM-IV diagnostic criteria for autistic disorder, offering a clear explanation of each component.
DSM-IV Diagnostic Criteria for Autistic Disorder
According to the DSM-IV, a diagnosis of autistic disorder required meeting a total of six or more criteria from categories (1), (2), and (3) listed below, with at least two from category (1), and at least one each from categories (2) and (3). Furthermore, onset had to be prior to age 3 years (Criterion B), and the disturbance not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder (Criterion C).
Criterion A: Qualitative Impairment in Social Interaction
This criterion focused on difficulties in social interaction, requiring at least two of the following to be present:
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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. This refers to challenges in using and understanding nonverbal cues that are crucial for typical social exchanges. For example, an individual might avoid eye contact, have limited facial expressions that don’t match their emotions, or use body language that is not aligned with social norms.
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Failure to develop peer relationships appropriate to developmental level. This indicates difficulty in forming friendships and social connections with peers. This isn’t just about being shy; it’s about a fundamental lack of understanding of social reciprocity and the give-and-take in friendships. For instance, a child might struggle to engage in cooperative play or understand the nuances of social games.
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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). This describes a reduced drive to share positive experiences with others. Typically, children will naturally want to show a parent a drawing they made or point out something interesting they see. In autism, this spontaneous sharing may be less frequent or absent.
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Lack of social or emotional reciprocity. This is a core feature of autism, referring to difficulties in the back-and-forth nature of social interactions. Individuals may struggle to understand and respond to the emotions of others, or to engage in reciprocal emotional exchanges. For example, they might not respond to social cues for interaction or struggle to understand how their actions affect others emotionally.
Criterion B: Qualitative Impairments in Communication
This criterion addressed challenges in communication, requiring at least one of the following:
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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). This refers to significant delays in language development or a complete absence of spoken language. Crucially, this criterion specifies that the lack of spoken language is not compensated for by other forms of communication, such as gestures.
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In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others. Even when individuals with autism develop spoken language, they may still have significant difficulties using language effectively in social conversations. This can include trouble initiating conversations, keeping a conversation going, or understanding the social rules of conversation.
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Stereotyped and repetitive use of language or idiosyncratic language. This involves unusual patterns in language use. This could manifest as repeating the same phrases or words (echolalia), using language in a repetitive or rigid way, or using language with idiosyncratic meanings that are not readily understood by others.
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Lack of varied, spontaneous, make-believe play or social imitative play appropriate to developmental level. This points to difficulties in imaginative and social play. Children with autism may show less interest in pretend play, struggle to engage in imaginative scenarios, or have difficulty imitating others in play scenarios, which are all important aspects of typical development.
Criterion C: Restricted, Repetitive, and Stereotyped Patterns of Behavior, Interests, and Activities
This criterion focused on restricted and repetitive behaviors, interests, and activities, requiring at least one of the following:
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Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus. This describes intense and fixated interests that are unusual in their scope or focus. These interests can be all-consuming and may dominate the individual’s thoughts and activities. For example, an intense interest in train schedules or specific types of machinery, pursued to an exceptional degree.
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Apparently inflexible adherence to specific nonfunctional routines or rituals. This refers to a need for sameness and resistance to change. Individuals may develop rigid routines or rituals that they must follow, and deviations from these routines can cause distress. These routines often appear to serve no clear functional purpose.
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Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements). These are repetitive physical movements that are often characteristic of autism. Examples include hand-flapping, rocking, spinning, or other repetitive body movements.
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Persistent preoccupation with parts of objects. This describes an unusual focus on specific parts of objects rather than the whole object. For example, a child might be fascinated by the wheels of a toy car, spinning them repeatedly, rather than engaging with the car in a typical play scenario.
Criterion B: Delays or Abnormal Functioning Before Age 3
In addition to the criteria above, the DSM-IV required that delays or abnormal functioning be present in at least one of the following areas, with onset prior to age 3 years:
- Social interaction
- Language as used in social communication
- Symbolic or imaginative play
This criterion emphasized that the signs of autism must be evident early in development.
Criterion C: Exclusion of Rett’s Disorder and Childhood Disintegrative Disorder
Finally, the DSM-IV diagnosis of autistic disorder required that the disturbance was not better explained by Rett’s Disorder or Childhood Disintegrative Disorder, which are other developmental conditions.
Reference
*American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., rev.). Washington DC: Author. (Pg. 75)
