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:
EXAMPLEIf 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.
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.
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:
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):
Additionally, when applicable, the DSM-5 provides specific criteria for defining the disorder with each diagnosis:
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||
|Level 2: Requires substantial support||Marked deficits with limited initiations and reduced or atypical responses||Obvious to the casual observer and occur across contexts||
|Level 3: Requires very substantial support||Minimal social communication||Marked interference in daily life||
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: