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Other Symptoms and Requirements for ASD Diagnosis

Author: Capella Partnered with CARD

what's covered

This lesson will explore other symptoms and requirements for the diagnosis of ASD by defining and discussing the following:

Other Symptoms
Specifiers
Severity Specifiers
Differences Between Current Diagnostic Criteria and Previous DSM-IV Criteria

1. Other Symptoms

As a reminder before we start today's lesson, the DSM-5 states that for a diagnosis of ASD (299.00), the individual must meet the following criteria:

a. Social communication and social interaction deficits (all three)

b. Restrictive, repetitive patterns of behavior, interests, or activities (at least two)

c. Symptoms must present in early development period (may not fully manifest until social demands exceed limited capacities)

d. Symptoms together cause significant impairment in other areas of everyday functioning

e. Symptoms are not better described by another DSM-5 diagnosis

In addition to meeting the criteria described above, symptoms must be present in the early developmental period. In other words, if a child develops typically and then starts to show the symptoms described above during adolescence, he or she would not qualify for an ASD diagnosis. However, it is important to note that some symptoms are less likely to fully manifest until the child has greater social demands placed on her.

EXAMPLE

If a toddler has no siblings, does not attend daycare, and has very little interaction with neighbors or peers, then her caregivers may not notice many of the signs of social deficits because the child has had little in the way of social demands placed on her. As she begins to interact with other children more, the seriousness of her social deficits may become clearer.

In order to qualify for an ASD diagnosis, symptoms must cause clinically significant impairment in social, occupational, or other important areas of current functioning. Put simply, ASD does not simply mean that the child is different from other children but, rather, that their deficits are severe enough to affect their quality of life on a daily basis.

For instance, social deficits that result in the child making few or no meaningful peer relationships would qualify as clinically significant. Similarly, communicative deficits that are severe enough that the child cannot tell his caregivers what he wants, thereby leading to tantrums, would cause clinically significant distress for him and his family. Finally, if a child’s obsession with engaging in repetitive behavior takes up so much of his time that he never develops any other leisure skills, his quality of life is likely to suffer to a clinically significant degree.

did you know

As awareness of ASD has risen in recent decades, it has become a somewhat popular topic in the general media. As a result, some people may casually declare themselves to have ASD or Asperger’s disorder if they are particularly good at using computers or are particularly socially awkward. It is important to keep in mind, however, that ASD is not the same as having a unique and quirky personality.

If a person is highly socially awkward and would rather spend all of their time memorizing statistics, but still engages in the social behaviors needed to make friends and function at work and at home, they likely do not qualify for an ASD diagnosis. There are likely thousands of people who find social interaction annoying or even terrifying and who would rather spend all of their time engaging in one or two particular hobbies, but this does not mean they have ASD.

For diagnostic purposes, such traits must be so severe that they prevent people from succeeding independently in their social, family, or academic lives. Intellectual disability and global developmental delay must be ruled out. To receive an ASD diagnosis, the DSM requires that an individual’s symptoms cannot be better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and ASD frequently co-occur. However, the symptoms of each disorder are distinct, and all must be present in order for both diagnoses to apply.

2. Specifiers

In addition to meeting the criteria for ASD, the diagnosis includes specifiers indicating certain features of the disorder. A specifier provides the etiology and other important features of the presenting symptoms that are relevant to the treatment of the diagnosed condition.

Specifiers are not intended to be mutually exclusive or jointly exhaustive, therefore, more than one specifier may be given for a particular diagnosis. If a diagnosis requires a specifier, the diagnostic criteria set will include the instruction “specify” or “specify if."

The DSM-5 indicates that the diagnosis of ASD is to specify the following:

With or without accompanying intellectual impairment
With or without accompanying language impairment
Associated with a known medical or genetic condition or environmental factor (e.g., ASD with Rett syndrome; ASD with fragile X)
Associated with another neurodevelopmental, mental, or behavioral disorder
With catatonia

The age and pattern of onset should also be specified for ASD. Symptoms are typically identified during the second year of life (12-24 months of age) but may be observed earlier than 12 months or later than 24 months, depending on the individual and the severity or subtleness of symptoms in day-to-day context.

The pattern of onset description might include information about early developmental delays or losses of social or language skills. Some children with ASD demonstrate developmental plateaus or regression, with a gradual or rapid deterioration in skills (social language or language). This information is important because these types of losses are rare with other disorders and can serve as a red flag for ASD, distinguishing symptoms of ASD from other developmental delays or disorders.

Early history is also specified, such as age of perceived onset, pattern of onset, and loss of skills (including timing):

ASD with onset before 20 months and loss of words
ASD with onset before 32 months and loss of social skills
ASD with no clear onset and no loss of skills

3. Severity Specifiers

Additionally, when applicable, the DSM-5 provides specific criteria for defining the disorder with each diagnosis:

Severity (e.g., mild, moderate)
Descriptive features (e.g., with good to fair insight, in a controlled environment)
Course (e.g., in partial remission, in full remission, recurrent)

However, not all disorders include course, severity, and descriptive feature specifiers.

Severity specifiers are provided to guide clinicians in rating the intensity, frequency, duration, symptom count, or other severity indicator of a disorder. Severity specifiers are indicated by the instruction “specify current severity” in the criteria set and include disorder-specific definitions.

DSM-5 instructs that an ASD diagnosis should include severity specifiers (indicated by the level of support needed to address symptoms) for each of the two domains – social communication and restrictive repetitive behaviors – recorded separately for each domain.

The severity specifiers for ASD identify the level of support needed to address symptoms related to both the social communication impairments and the restrictive repetitive behaviors, with the recognition that severity may vary by context and fluctuate over time.

The level of support needed for social communication difficulties and restricted, repetitive behaviors are recorded separately according to the descriptive severity categories in the table.

Severity Level for ASD	Social Communication	Restricted Interests & Repetitive Behaviors	Examples
Level 1: Requires support	Without support, some significant deficits in social communication	Significant interference in at least one context	Difficulty initiating and responding to social interactions Observed as having decreased interest in others Speaks and communicates in full sentences, but difficulty engaging in conversation Attempts to make friends are often odd and unsuccessful Marked inflexibility Difficulty switching activities Poor planning and organization skills that impact independent functioning
Level 2: Requires substantial support	Marked deficits with limited initiations and reduced or atypical responses	Obvious to the casual observer and occur across contexts	Marked impairments noticeable even with supports in place Limited response and initiations to social interactions Speaks in simple limited sentences Limited and odd nonverbal communication Interactions limited to narrow special interests Inflexibility in behavior Difficulty coping with change Restricted or repetitive behavior that interferes with functioning
Level 3: Requires very substantial support	Minimal social communication	Marked interference in daily life	Severe verbal and nonverbal communication causes significant impairment in functioning Limited social initiations and minimal response to social overtures from others Few words of intelligible speech Rarely initiates and when does may use unusual approaches to get needs met Responds only to very direct social initiations Extreme inflexibility with coping with changes Repetitive or restricted behaviors markedly interfere with all other areas of functioning Marked distress changing focus or action

4. Differences Between Current Diagnostic Criteria and Previous DSM-IV Criteria

The largest change from DSM-IV to DSM-5 is that the various diagnostic subtypes (Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder Not Otherwise Specified) have been collapsed into the single diagnosis of ASD.

Whereas DSM-IV delineated several separate and distinct disorders that shared characteristics of delay, the DSM-5 places these disorders under one umbrella and distinguishes subtypes not by name but by level of severity and other specifiers.

An individual diagnosed with one of the four pervasive developmental disorders under DSM-IV should still meet the criteria for ASD under DSM-5, or another more accurate diagnosis under DSM-5. Individuals with marked impairment in social communication, but who do not otherwise meet the diagnostic criteria for ASD, should be assessed for social communication disorder (315.39).

Additional considerations about ASD:

Individuals do not “grow out” of their ASD.
Early diagnosis is key.
Early and intensive intervention is key.
Individuals with ASD can make significant progress.
Teaching strategies and skill targets should be chosen based upon the specific needs of each individual.

summary

You began today's lesson with a review of all the criteria that an individual must meet to qualify for an ASD (299.00) diagnosis. You learned that in addition to meeting these criteria, these other symptoms must appear during early development and must cause clinically significant impairment. It is important to note that just because a person is socially awkward and spends all of their time engaging in one or two particular hobbies, this does not mean they have ASD. Traits must be so severe that they prevent people from succeeding independently in their social, family, or academic lives.

You also learned that in addition to meeting the criteria for ASD, the diagnosis includes specifiers indicating certain features of the disorder, providing the etiology and other important features of the presenting symptoms that are relevant to the treatment of the diagnosed condition. Severity specifiers guide clinicians in rating the intensity, frequency, duration, symptom count, or other severity indicators of a disorder. Finally, you learned about the differences between current diagnostic criteria and previous DSM-IV criteria, the largest change being that the various diagnostic subtypes have been collapsed into the single diagnosis of ASD.