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Diagnostic Criteria for Autism Spectrum Disorder in the DSM-5
DSM stands for "Diagnostic and Statistical Manual of Mental Disorders," which is a manual published by the American Psychiatric Association. The manual includes classifications of psychiatric disorders for use by medical and mental health professionals. Clinicians may refer to versions of the DSM to look for diagnostic codes of different disorders and examine criteria for diagnosis. About 25% of the disorders are specific to children and are in the section of "Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence." Autism and related disorders have been specifically included in different versions of the DSM since 1980.
The latest edition of the DSM, DSM-5, made significant changes to the diagnostic criteria for autism and related disorders. In DSM-IV, five separate diagnoses were classified under the heading "Pervasive Development Disorders:" Autistic disorder, Asperger Syndrome, Pervasive Development Disorder Not Otherwise Specified (PDD-NOS), Rett Syndrome, and Childhood Disintegrative Disorder. The Pervasive Development Disorder category no longer appears in DSM-5, and Autistic disorder, Asperger Syndrome, and PDD-NOS have now been combined into one label: Autism Spectrum Disorder (ASD).
The criteria in the DSM-5 for diagnosing ASD include 3 listed deficits in social communication and social interactions. Clinicians must be sure that these characteristics are not due to developmental delay alone. To be diagnosed with ASD, an individual must meet all three of the following criteria:
- Difficulties in social emotional reciprocity, including trouble with social approach, back and forth conversation, sharing interests with others, and expressing/understanding emotions.
- Difficulties in nonverbal communication used for social interaction including abnormal eye-contact and body language and difficulty with understanding the use of nonverbal communication like facial expressions or gestures for communication.
- Deficits in developing and maintaining relationships with other people (other than with caregivers), including lack of interest in others, difficulties responding to different social contexts, and difficulties in sharing imaginative play with others.
The criteria in the DSM-5 also include demonstrating at least 2 of the following 4 restricted and repetitive behavior, interests, or activities:
- Stereotyped speech, repetitive motor movements, echolalia (repeating words or phrases, sometimes from television shows or from other people), and repetitive use of objects or abnormal phrases.
- Rigid adherence to routines, ritualized patterns of verbal or nonverbal behaviors, and extreme resistance to change (such as insistence on taking the same route to school, eating the same food because of color or texture, repeating the same questions); the individual may become greatly distressed at small changes in these routines.
- Highly restricted interests with abnormal intensity or focus, such as a strong attachment to unusual objects or obsessions with certain interests, such as train schedules.
- Increased or decreased reactivity to sensory input or unusual interest in sensory aspects of the environment, such as not reacting to pain, strong dislike to specific sounds, excessive touching or smelling objects, or fascination with spinning objects.
Under DSM-5, ASD is now diagnosed by symptoms based on both the current functioning and past functioning of an individual. This new observational criteria will allow clinicians to diagnose people who may have shown some signs early in development, but whose symptoms didn’t become clear until adolescence or adulthood.
In addition to the changes in criteria for the ASD diagnosis, the new DSM-5 has also added a severity rating. The new DSM offers ways to identify ASD levels of severity for each individual. The 3 levels of severity include:
- Level 1. "REQUIRING SUPPORT": Individuals with this level of severity have difficulty initiating social interactions, may exhibit unusual or unsuccessful responses to social advances made by others, and may seem to have decreased interest in social interactions. Additionally, repetitive behaviors may interfere with daily functioning. These individuals may have some difficulty redirecting from their fixed interests.
- Level 2. "REQUIRING SUBSTANTIAL SUPPORT": Individuals with this level of severity exhibit marked delays in verbal and non-verbal communication. Individuals have limited interest or ability to initiate social interactions and have difficulty forming social relationships with others, even with support in place. These individuals’ restricted interests and repetitive behaviors are obvious to the casual observer and can interfere with functioning in a variety of contexts. High levels of distress or frustration may occur when interests and/or behaviors are interrupted.
- Level 3. "REQUIRING VERY SUBSTANTIAL SUPPORT": This level of severity causes individuals with ASD severe impairment in daily functioning. These individuals have very limited initiation of social interaction and minimal response to social overtures by others and may be extremely limited in verbal communication abilities. Preoccupations, fixed rituals, and/or repetitive behaviors greatly interfere with daily functioning and make it difficult to cope with change. It is very difficult to redirect this person from fixated interests.
The DSM-5 was released in May, 2013, and clinicians are expected to follow the new criteria as they become familiar with the new guidelines.