Understanding DSM-5 Criteria for ASD Diagnosis

For professionals in the United States and globally involved in diagnosing mental health conditions, the American Psychiatric Association (APA)’s Diagnostic and Statistical Manual of Mental Disorders (DSM) stands as the primary resource. The fifth edition, DSM-5, released in 2013, outlined specific criteria for autism spectrum disorder (ASD) diagnosis, which were further clarified in the 2022 DSM-5-TR text revision. Understanding these criteria is crucial for accurate ASD diagnosis.

Core DSM-5 Diagnostic Criteria for Autism Spectrum Disorder

The DSM-5 establishes that an ASD diagnosis necessitates “persistent deficits in social communication and social interaction across multiple contexts.” This broad statement is then detailed through specific criteria, which are presented in full below, courtesy of the APA. It’s important to note that the DSM-5-TR update refined the wording of criterion A, changing “manifested by the following” to “as manifested by all of the following” to emphasize the comprehensive nature of the diagnostic requirements.

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):

1. Deficits in social-emotional reciprocity: This ranges from noticeable issues in back-and-forth conversation and social approach, to a diminished sharing of emotions, interests, or affect, and can extend to a complete lack of initiation or response in social interactions.
2. Deficits in nonverbal communicative behaviors used for social interaction: These deficits are varied, from poorly integrated verbal and nonverbal communication, to abnormalities in eye contact and body language, challenges in understanding and using gestures, and even a complete absence of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships: The spectrum of these difficulties includes problems adjusting behavior across different social situations, struggles with imaginative play or forming friendships, and a lack of interest in peers.

Specify current severity: The severity level is determined by the degree of social communication impairments and the restricted, repetitive patterns of behavior.

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):

1. Stereotyped or repetitive motor movements, use of objects, or speech: Examples include simple motor stereotypies, lining up toys, object flipping, echolalia, and using idiosyncratic phrases.
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior: This can manifest as extreme distress over minor changes, difficulties with transitions, rigid thinking patterns, specific greeting rituals, or a need to follow the same routes or eat the same foods daily.
3. Highly restricted, fixated interests that are abnormal in intensity or focus: This involves a strong attachment to or preoccupation with unusual objects, or excessively focused and perseverative interests.
4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment: This can include apparent indifference to pain or temperature, negative responses to specific sounds or textures, excessive touching or smelling of objects, or visual fascination with lights or movement.

Specify current severity: Severity is also based on the level of social communication impairments and restricted, repetitive behaviors.

C. Symptoms must be present in the early developmental period (but may not become fully apparent until social demands exceed limited capacities, or they might be masked by learned strategies later in life).

D. Symptoms must cause clinically significant impairment in social, occupational, or other important areas of current functioning.

E. These disturbances should not be better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. It’s important to note that intellectual disability and autism spectrum disorder can co-occur. For a dual diagnosis, social communication deficits must be demonstrably below what’s expected for the individual’s general developmental level.

Note: Individuals with a previous DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should now be diagnosed with autism spectrum disorder under DSM-5. For individuals exhibiting marked social communication deficits without meeting full ASD criteria, Social (Pragmatic) Communication Disorder should be considered.

Specify if:

• With or without accompanying intellectual impairment
• With or without accompanying language impairment (Utilize additional codes for associated medical or genetic conditions)
• Associated with another neurodevelopmental, mental, or behavioral disorder (Utilize additional codes for associated disorders)
• With catatonia
• Associated with a known medical or genetic condition or environmental factor

Social (Pragmatic) Communication Disorder: DSM-5 Criteria

A. Persistent difficulties in the social use of verbal and nonverbal communication, indicated by all of the following:

1. Deficits in using communication for social purposes: This includes challenges in greetings, sharing information, and adapting communication to the social context.
2. Impairment in adapting communication to context and listener needs: This involves difficulties in modifying communication style for different settings (e.g., classroom vs. playground) or audiences (child vs. adult), and avoiding overly formal language when inappropriate.
3. Difficulties following conversation and storytelling rules: This includes challenges in turn-taking, rephrasing misunderstandings, and using verbal and nonverbal cues to regulate interaction.
4. Difficulties understanding implicit communication: This involves struggles with inferences, nonliteral language (idioms, humor, metaphors), and ambiguous language that relies on context for interpretation.

B. These deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination.

C. The onset of symptoms is in the early developmental period (but deficits may not fully manifest until social communication demands exceed limited capacities).

D. Symptoms are not attributable to other medical or neurological conditions, low abilities in word structure and grammar, intellectual disability, autism spectrum disorder, global developmental delay, or other mental disorders.

For further information and resources, the Autism Speaks’ Autism Response Team is available to provide support and guidance.