The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) is a manual often cited in scientific journals; medical professionals like psychiatrists and pediatricians refer to it when diagnosing—but for some of us it appears to be a bit of a daunting read reserved for those with multiple abbreviations accompanying their name.
The name of the handbook, The Diagnostic and Statistical Manual of Mental Disorders (or the DSM-5) contributes to the intimidation factor. While it was never intended as a beach read for the public, the DSM-5 contains a lot of diagnostic information that may be useful for educators and parents, in addition to its intended medical and research audience.
Most doctors in the US use the manual as the authoritative guide when diagnosing autism spectrum disorders (ASD). For medical professionals without a lot of autism related experience, the DSM-5 provides guidelines and criteria to facilitate consistent and reliable diagnoses.
It may be a valuable diagnostic tool, but it’s also been criticized by many clinicians—specifically criticism regarding its validity, reliability and utility (Young, 2016). Issues relating to overdiagnosis and the risk of pathologizing normal behavior or conditions are further areas of concern according to Young (2016).
Another area of criticism of the revised handbook is the narrowing of criteria (as to what constitutes an autism spectrum disorder) in the DSM-5, to the extent that some on the threshold of the spectrum may be excluded. The Diagnostic and Statistical Manual of Mental Disorders (4th ed.,; DSM-IV; American Psychiatric Association, 1994) did not use a singular diagnostic category for autism like the revised edition. Instead the following distinct conditions were used:
- Autistic disorder
- Asperger’s disorder
- Childhood disintegrative disorder
- Pervasive developmental disorder-not otherwise specified (PDD-NOS)
The DSM-5 absorbed these distinct conditions under the umbrella term of autism spectrum disorder. Many diagnosed with asperger’s felt the condition should have remained as a separate condition, related to but not quite autism. The DSM-5 does state that those with a “well-established” diagnosis of asperger’s and PDD-NOS should be diagnosed with autism spectrum disorder.
The DSM-5 added a new condition, called social communication disorder, that can be diagnosed in those who do not meet the criteria for ASD. The DSM-5 also added symptoms of a sensory nature, listing hyper and hyposensitivity as a possible characteristic of ASD. Some feel sensory issues should have been included from the start, while others feel it leads to misdiagnosis.
The DSM-5 may have certain shortcomings, but it is helpful in identifying traits and symptoms that may indicate a child needs to be assessed for ASD. The following discussion about the criteria found in the DSM-5 should not be used to self-diagnose autism; instead parents who think their child may display some of these behaviors should share this with the child’s pediatrician.
DSM-5 autism spectrum disorder diagnostic criteria
The criteria for an autism diagnosis, according to the DSM-5, includes signs and symptoms and it states how many of these need to be present. The criteria can be divided into two core areas: social communication difficulties and restricted/repetitive and/or sensory behaviors.
Deficits or difficulty with social communication
According to the manual, a child should have ongoing difficulties in all three areas of social communication and interaction.
- The first area specifies persistent deficits in “social-emotional reciprocity”. This would probably manifest in difficulties with initiating social interaction (or an atypical way of approaching such interactions), or the child may find it challenging to respond appropriately with back-and-forth conversation during interactions, and find it difficult to share interests and emotions
- The second area is focused on nonverbal communication and the challenges the child may experience; manifesting in difficulties with eye contact, appropriate facial expressions and body language typically utilised for social interaction
- The last area’s deficits may show up as a child’s lack of forming, keeping and understanding relationships such as friendships. To maintain relationships, adjustments to behavior to suit a certain social context are needed—which may be an area of difficulty for someone on the spectrum. Furthermore, the child may find it hard to participate in imaginative play and show little interest in other children
Restricted, repetitive patterns of behavior
This kind of behavior should be present (or shown previously) and for a diagnosis at least two of these should be apparent:
- Repetitive motor movements, this often manifests in a particular way in which the child lines up toys instead of playing with them, or repetitive speech patterns like echolalia or repeating phrases from movies at inappropriate times
- Inflexibility when it comes to routines and patterns of behavior and an insistence on sameness—the child may display extremely rigid behavior, insisting on eating the same meal daily or watching only one show repeatedly
- An atypically intense interest which is fixated and highly restricted, for example a fixation with regards to a specific object or a field of interest like math or trains
- The DSM-5 added hyper- or hyporeactivity to sensory stimuli (which was not a symptom identified in previous editions). The child may overreact to neutral stimuli like tags in clothing, or seek sensory input with behaviors like smelling and touching things excessively
Even if these symptoms are present, further requirements are still needed for an autism diagnosis. For example, the symptoms should be present from early on—it is however possible that full manifestation only occurs later due to circumstances. These symptoms should cause significant problems in important areas of the child’s life and should not be better explained by intellectual disability or global development delay.
The diagnostic criteria list in the DSM-5 also mentions that those with a “well-established DSM-IV diagnosis” of asperger’s, PDD-NOS or autistic disorder should receive an autism spectrum disorder diagnosis.
This is a summary of the criteria for autism spectrum disorder. The DSM-5 contains a detailed list of signs and symptoms with examples for illustrative use. If there is any sign that a child may be on the spectrum, a medical professional should be consulted.
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Accuracy of criteria
Many parents fear misdiagnosis, actually most of us fear that Big Pharma could be deluding us into a diagnosis that will line their pockets—as we over medicate normal behavior that they pathologized and monetized. Some researchers have also expressed doubts about the diagnostic criteria of the DSM-5; in this regard, a number of reviews and analysis (to determine how the DSM-5 affects ASD diagnosis) have been undertaken.
Kulage et al. (2014) conducted a meta-analysis to see the effect of the changes of the DSM-5 on ASD. The authors concluded that changes would likely lead to a decrease in individuals diagnosed with ASD. Importantly, the authors felt research was needed on policies for those who lack diagnosis but who need assistance.
This recommendation should be kept in mind when a child’s symptoms are not such that he/she meets the diagnostic criteria for ASD, but serious enough to cause impairment. There may be help for symptoms that cause difficulty for the child, even if such symptoms do not qualify for an autism or other neurodevelopmental disorder diagnosis.
The DSM-5 can be a handy tool for educators and parents to alert them to symptoms that need to be discussed with a medical professional. Early diagnosis leads to early intervention, whether the DSM-5 aids this goal will have to be determined by research.
It is important to keep in mind that the DSM-5 is published by the American Psychiatric Association and some feel it is aimed mainly at North-America. Another diagnostic system is more global in scope—the International Classification of Diseases (ICD-11) developed and updated by the World Health Organization is used by the international medical community and also for insurance coding purposes.
Its criteria for an autism diagnosis is similar to the DSM-5, but there are a few differences; for example the DSM-5 mentions that intellectual disability and autism can occur simultaneously while the ICD-11 delves into details for distinguishing between autism with and without intellectual disability.
Whatever system of diagnosis is used by your doctor or pediatrician, parents should ensure that all factors including the child’s history and coexisting conditions are considered for an accurate diagnosis. An early and accurate diagnosis is mentioned time and again by researchers when describing successful interventions for a child on the spectrum.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV Fourth Edition. Washington, D.C.: American Psychiatric Association, 1994.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Kulage, K., Smaldone, A., & Cohn, E. (2014). How Will DSM-5 Affect Autism Diagnosis? A Systematic Literature Review and Meta-analysis. Journal of Autism and Developmental Disorders, 44, 1918-1932.
Young G. (2016) DSM-5: Basics and Critics. In: Unifying Causality and Psychology. Springer, Cham. https://doi.org/10.1007/978-3-319-24094-7_22