Diagnosis of Autism Spectrum Disorder
In the past, there were several pervasive development disorders that could be diagnosed including Autism, Asperger's Disorder and Pervasive Development Disorder Not Otherwise Specified (PDD NOS).
With the release of the Diagnostic and Statistical Manual of Mental Disorders (the DSM; currently in its 5th edition), there were extensive changes made to the diagnosis criteria and categories.
Rather than multiple disorders, there is now a single condition called Autism Spectrum Disorder.
To be diagnosed with this condition, there must be:
A. Persistent/ongoing problems in social communication and social interaction across multiple settings as shown by the following. The problems must be happening either currently or be shown by history. (Please note that these are examples for illustration, not an exhaustive list)
1. Deficits in Social/Emotional Connections. These issues may range from failure to follow a back-and-forth conversation style; reduced sharing of interests and emotions; failure to start or respond to social interactions.
2. Deficits in nonverbal communication behaviors used for social interaction. Examples include an inability to maintain eye contact; poorly integrated verbal and nonverbal communication; problems understanding and using gestures in conversation (for example, waving hello or goodbye); lack of facial expression while talking.
3. Deficits in developing, maintaining and understanding relationships. This might include difficulties adjusting behavior to different social settings (for example with peers in a casual environment or with teachers/elders in a more formal situation); difficulties in sharing imaginative play with others or making friends; absence of interest in having or keeping friends.
The clinician is asked to specify the current severity of the deficits in Criteria A. There are three levels that can be chosen:
Level 1 - Requiring Support - Without supports in place, deficits in social communication cause noticeable impairments. The person has difficulty starting social interaction with others and displays responses to social overtures of others that are not typical or successful.
Level 2 - Requiring Substantial Support - There are marked (very noticeable) deficits in verbal and nonverbal social communication skills; social impairments are apparent even with supports in place; limited starting of social interactions; and reduced or abnormal responses to social overtures of others.
Level 3 - Requiring Very Substantial Support - There are severe deficits in verbal and nonverbal communication skills that cause severe impairments in functioning, very limited starting of social interactions, and minimal response to interactions by others.
B. Restricted, repetitive patterns of behavior, interests, or activities as shown by at least two of the following (either currently or by history, and again, these are examples, not an exhaustive list):
1. Stereotyped or Repetitive Motor Movements, Use of Objects, or Speech. This might include simple motor activities being performed over and over, such as hand flapping or rocking back and forth. Children might also be focused on lining up toys/objects in certain patterns or flipping them around while focusing intently on them. Issues with speech might include a practice known as echolalia. Echolalia is a verbal behavior in which children repeat what they hear over and over and over again.
2. Insistence on sameness, inflexible adherence to routines, or ritualized pattern of verbal and nonverbal behavior. Examples include extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take the same route or eat the same food every day.
3. Highly restricted, fixed interests that are abnormal in intensity or focus. For example, strong attachment or preoccupation with unusual objects (a teen who carries around a toy) or having one or two interests that are all they can will talk about or focus on.
4. Hyper- or hypo- reactivity to sensory input or unusual interest in sensory aspects of the environment. Examples include apparent indifference to pain/temperature, negative reactions to specific sounds or textures, excessive smelling or touching of objects, or visual fascination with lights or movement.
Again, with this group of symptoms, clinicians are asked to specify the current severity of the deficits in Criteria A. There are three levels that can be chosen:
Level 1 - Requiring Support - inflexibility of behavior causes significant interference with functioning in one or more areas of life (school, work, etc.). Difficulty switching between activities. Problems of organization and planning affect the person's independence.
Level 2 - Requiring Substantial Support - Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to casual observers and interfere with functioning in a variety of settings. Distress and/or difficulty changing focus or action.
Level 3 - Requiring Very Substantial Support - Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors severely interfere with functioning in all settings. Great distress/difficulty with changing focus or action.
C. Symptoms of autism spectrum disorder must be present in the early developmental period. However, they may not become fully displayed until social demands exceed the person's limited capabilities, or they may be masked by learned strategies later in life.
D. These symptoms cause a great deal of stress in the person's life and problems handling school, work, relationships, and other commitments.
E. These disturbances are not better explained by intellectual disabilities or global developmental delay.
There are also several specifiers that a clinician can apply to the diagnosis of autism spectrum disorder. These include:
- With or without accompanying intellectual ability
- With or without accompanying language impairment
- Associated with a known medical condition or genetic condition or environmental factor
- Associated with another neurodevelopmental, mental or behavioral disorder
- With catatonia