The American Psychiatric Association (APA) has updated the standards for diagnosing autism spectrum disorder. Released in 2013, the standards are contained in the fifth edition of the APA's Diagnostic and Statistical Manual of Mental Disorders. The new standards are known as DSM-5 criteria, from the short name of this manual.
Overview of DSM-5 criteria
The DSM-5 criteria were developed to provide standards for health-care professionals to diagnose a range of disorders and conditions.
The DSM-5 replace previous criteria, known as DSM-IV (TR) from 2000. These, in turn, revised DSM-IV, which were published in 1994.
The table below outlines the main differences between DSM-5 and DSM-IV.
| DSM-5 (2013) | DSM-IV (2000; 1994) |
|---|---|
| Uses one umbrella term, autism spectrum disorder (ASD) | Listed five separate disorders: autistic disorder, Asperger's disorder, PDD-NOS, childhood disintegrative disorder, Rett syndrome |
| Uses two categories of symptoms to diagnose disorder: social communication and restricted repetitive behaviours | Used three categories of symptoms to diagnose disorder: communication; social interaction; restricted interests and behaviours |
Includes a three-level scale to reflect how severely a child is affected in each category and, as a result, the amount of support they need A person at level 1 (least severe) needs a regular amount of support, but a person at level 3 (most severe) needs very substantial support. With improvement, a child can move down a level. | No scale |
Main categories of ASD symptoms under DSM-5
Difficulties with social communication
A child diagnosed with ASD has ongoing current or past difficulties in all three areas below.
- Deficits in social-emotional reciprocity (giving support to and receiving support from others), which can include:
- abnormal social approach
- failing to engage in regular back-and-forth conversation
- reduced sharing of interests or feelings
- failing to start or respond to social interactions
- Deficits in non-verbal communication needed for social interaction, which can include:
- poorly combining words with facial expressions, gestures or other forms of non-verbal communication
- abnormal eye contact and body language
- difficulty in understanding and using gestures
- lack of facial expressions or non-verbal communication
- Deficits in understanding, developing and maintaining relationships, which can include:
- difficulties adjusting behaviour to different situations
- difficulties in sharing imaginative play or making friends
- lack of interest in peers
If a child has problems with social communication but no other symptoms that meet the criteria for ASD, they should be evaluated for a condition called social pragmatic communication disorder.
Patterns of restricted repetitive behaviour
A child with ASD has ongoing current or past difficulties in at least two of the four areas below.
- Repetitive movements, use of objects or speech, which can include:
- repeated gestures such as hand flapping or finger flicking
- repeated lining up of toys or spinning objects
- automatic repeating of words or other sounds (known as echolalia) or use of odd or unusual phrases
- Rigid insistence on sameness, which can include:
- extreme distress at small changes or difficulties with transitions, for example moving house
- rigid following of routines, such as needing to take the same route or eat the same food each day
- ritualized patterns of verbal or non-verbal behaviour, such as ritualized greetings or rigid thinking patterns
- Highly restricted, fixated interests, which can include:
- abnormally intense or focused interest in things, such as a strong attachment to or pre-occupation with unusual objects
- excessively circumscribed (limited) or obsessive interest in things such as bus routes, numbers or letters
- Hyper-reactivity (over-reaction) or hypo-reactivity (indifference) to sights, sounds or sensations or an unusual interest in the sights and sounds in the environment, which can include:
- apparent indifference to pain or heat and cold
- strong, negative reactions to specific sounds or textures
- excessive smelling or touching of objects
- visual fascination with lights or movement
Other standards within the DSM-5
Three other standards exist for a valid diagnosis of autism spectrum disorder.
Early childhood symptoms
The symptoms of ASD must be present from early childhood, even if they are only recognized as a child grows and faces situations they do not have the skills to manage. This guideline encourages earlier diagnosis and recognizes a child's range of symptoms and abilities as they get older.
Significant impairment
The symptoms must cause clinically significant impairment in social, occupational (day-to-day living) or other important areas of a child's current functioning.
Difficulties not explained by an intellectual disability or developmental delay
The symptoms and causes of the difficulties under autism spectrum disorder cannot be better explained by an intellectual disability or by a general developmental delay.
A child may have ASD as well as one of these other conditions:
- Fragile X syndrome, Rett syndrome or Down syndrome
- a seizure disorder such as epilepsy
- very low birth weight
- a history of exposure to environmental factors, as in fetal alcohol spectrum disorder
Why the new standards were developed
Researchers found that it made more sense to group the range of disorders previously in DSM-IV under the single term of ASD because they shared a common set of causes, symptoms, effects and genetic links. Now, when doctors make a diagnosis, they need only consider one disorder, ASD, instead of several possible disorders.
The new standards are also designed to help doctors make more specific, reliable and valid diagnoses. The different categories and the three-level scale offer a more scientific and accurate way of diagnosing individuals with ASD but remain sensitive to how the disorder might appear in each person.
Concerns about DSM-5
The DSM-5 criteria have been greeted with mixed reviews. Some are concerned that they could be interpreted too broadly or stop families pursuing a diagnosis. Others say that they could cause doctors to miss higher-functioning people or fail to understand the complexity of the disorder and how it can appear differently in one person compared with another.
Promise of DSM-5
There are fewer criteria in DSM-5, but they are stricter, more thorough and specific. Ultimately, however, no matter what terms are used in an ASD diagnosis, they do not define an individual. Every child is unique.
For more information about ASD, including services to help families and children, visit our Autism Spectrum Disorder Learning Hub.