The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), published by the American Psychiatric Association, is the primary resource for healthcare professionals in the US and globally when diagnosing mental health conditions. For autism spectrum disorder (ASD), the DSM-5 provides specific criteria that must be met for a diagnosis. Understanding these criteria is crucial for individuals, families, and professionals involved in autism care.
In 2013, the DSM-5 redefined autism diagnosis, emphasizing persistent challenges in social communication and interaction, along with restricted and repetitive behaviors. According to the DSM-5, an autism diagnosis hinges on demonstrating ongoing difficulties in social communication and social interaction across various situations. These difficulties are specifically manifested by deficits in social-emotional reciprocity, nonverbal communication used for social interaction, and the ability to develop, maintain, and understand relationships. Below, we outline the full DSM-5 diagnostic criteria for ASD, as provided with permission from the APA.
It’s important to note that in 2022, the APA released the DSM-5-TR%20was%20published%20in%202022.), a revised text version of the DSM-5. This revision included a key clarification, changing “manifested by the following” to “as manifested by all of the following” within the autism criteria as detailed by the APA. This change reinforces the need for all listed manifestations within each criterion to be considered for a diagnosis.
DSM-5 Diagnostic Criteria for Autism Spectrum Disorder: A Detailed Look
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):
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Deficits in social-emotional reciprocity: This ranges from struggles with typical back-and-forth conversation, a reduced sharing of interests or emotions, to a lack of initiation or response in social interactions. For example, an individual might not readily engage in the give and take of conversation, may not show interest in sharing enjoyment, or might not respond when others initiate interaction.
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Deficits in nonverbal communicative behaviors used for social interaction: This includes challenges with integrating verbal and nonverbal communication, abnormalities in eye contact and body language, difficulties understanding and using gestures, or even a lack of facial expressions and nonverbal communication. An example could be someone who struggles to use gestures effectively while speaking, misinterprets social cues like body language, or maintains atypical eye contact during conversation.
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Deficits in developing, maintaining, and understanding relationships: This can present as difficulties adjusting behavior across different social situations, problems with imaginative play or making friends, or a lack of interest in peers. For instance, a person might find it hard to adapt their behavior to fit different social contexts like a classroom versus a playground, struggle to engage in pretend play with others, or show limited interest in forming friendships.
Specify current severity: Severity levels are determined by the degree of social communication impairments and the extent of 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):
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Stereotyped or repetitive motor movements, use of objects, or speech: This can include simple motor stereotypies like hand-flapping, repetitive use of objects such as lining up toys, or speech patterns like echolalia (repeating words or phrases) or using idiosyncratic phrases. For example, a child might repeatedly flap their hands when excited, obsessively arrange toys in lines, or consistently repeat phrases heard elsewhere.
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Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior: This can manifest as extreme distress with minor changes, difficulty with transitions, rigid thinking patterns, greeting rituals, or a need to follow the same routines daily, like taking the same route or eating the same food. An individual might become highly distressed by small changes in routine, find transitions very challenging, or exhibit rigid thought patterns and insistence on specific rituals.
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Highly restricted, fixated interests that are abnormal in intensity or focus: This involves strong attachment to or preoccupation with unusual objects, or excessively focused or perseverative interests. For example, a person might develop an intense preoccupation with specific, unusual objects, or have extremely narrow and focused interests that dominate their attention.
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Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment: This can include apparent indifference to pain or temperature, adverse responses to specific sounds or textures, excessive touching or smelling of objects, or visual fascination with lights or movement. An individual might show a lack of typical response to pain, be overly sensitive to certain sounds, excessively touch objects, or be intensely fascinated by visual stimuli like lights.
Specify current severity: Severity is also based on the intensity of restricted, repetitive behaviors, interests, and activities, in addition to social communication challenges.
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).
D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
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.
Note: The DSM-5 clarifies that individuals previously diagnosed with DSM-IV autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should now be diagnosed with autism spectrum disorder. For individuals with significant social communication deficits who do not fully meet ASD criteria, Social (Pragmatic) Communication Disorder should be considered.
Specify if: (These specifiers help provide a more detailed and individualized diagnosis)
- 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: An Important Distinction
The DSM-5 also outlines criteria for Social (Pragmatic) Communication Disorder. This diagnosis is for individuals who present with difficulties in the social use of verbal and nonverbal communication, but who do not demonstrate the restricted, repetitive behaviors required for an autism spectrum disorder diagnosis. Criteria include difficulties in using communication for social purposes, adapting communication to different contexts, following conversation rules, and understanding non-literal language. It is crucial to differentiate between ASD and Social Communication Disorder for accurate diagnosis and appropriate support.
Understanding the Importance of DSM-5 in Autism Diagnosis
The DSM-5 criteria provide a standardized framework for diagnosing autism spectrum disorder. This framework ensures more consistent and reliable diagnoses across different professionals and settings. While these criteria are essential, diagnosis should always be made by qualified professionals through comprehensive evaluation, taking into account individual presentation and history. If you have concerns about autism for yourself or someone you know, seeking professional assessment is the most important step towards understanding and support.
