Autism and Neurodiversity

The DSM-5-TR

The DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders 5^th Edition, Text Revision)  is produced by the American Psychiatric Association. It is used by professionals like psychiatrists, paediatricians, psychologists, speech therapists, occupational therapists when diagnosing autism. It contains a list of the signs and symptoms (at ETHAN we prefer the term characteristics) of autism spectrum disorder (ASD) and how many of these must be present to confirm a diagnosis of autism.

Please note: This section is for educational purposes and is not a substitute for medical advice or to meant to be used as a primary diagnostic tool. The language is from the DSM-5 and much of the language is based on the medical model, is deficit-based and does not highlight the core strengths of autism (as what is being shown in many research papers).

To meet the criteria for Autism as per the DSM-5-TR , five groups of diagnostic criteria must be met (A-E). The biggest groups are criteria A and B. Criteria A links to social, communication, and relationship differences, while criteria B speaks to routine, structure, repetition, special interests, and sensory issues. The other criteria are used to help differentiate autism from other conditions and/or diagnoses.

Autism: Criteria A

There are three subcategories for criteria A of Autism plus at least two of four types of restricted, repetitive behaviors. All three subcategories must be met in order for criteria A to be met. If a person has 2 of the three subcategories, criteria A would not be met for autism. 

Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text):

1. 1. Deficits (Differences) in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
   2. Deficits (Differences) in nonverbal communicative behaviours used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
   3. Deficits (Differences) in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behaviour to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

Autism: Criteria B

All three subcategories need to be present for the DSM-5 criteria A for autism. For criteria B to be met, only 2 of the four subcategories must be present. Criteria B broadly speaks to the need for routine, structure, knowing what to expect, and our sensory challenges. The direct language from the DSM-5 reads, “Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at least two of the following.”

Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

1. 1. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behaviour (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
   2. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
   3. Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment (e.g. apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

In the DSM, the last few criteria of any diagnosis code typically have to do with the disqualifies or rule-outs. The same is true here for Criteria C-E.

Specify current severity:

Severity is based on social communication impairments and restricted, repetitive patterns of behavior. For either criterion, severity is described in 3 levels: Level 3 – requires very substantial support, Level 2 – Requires substantial support, and Level 1 –requires support.

Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).

1. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
2. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.
3. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.

Specify if:

With or without accompanying intellectual impairment

With or without accompanying language impairment

Associated with a known medical or genetic condition or environmental factor

(Coding note: Use additional code to identify the associated medical or genetic condition.)

Associated with another neurodevelopmental, mental, or behavioral disorder

(Coding note: Use additional code[s] to identify the associated neurodevelopmental, mental, or behavioral disorder[s].

With catatonia (refer to the criteria for catatonia associated with another mental disorder)

(Coding note: Use additional code 293.89 catatonia associated with autism spectrum disorder to indicate the presence of the comorbid catatonia.

More simply put:

Criteria C: Autism is a neurodevelopmental condition (i.e., a neurodivergence). It is regarded as inborn and not acquired, and there must be evidence of it from early in life. It is important to realize (and the DSM includes states this) that Autistic traits may not become obvious until the person is under undue stress or in unsupportive environments. A person may also learn to mask Autistic traits early in life and in such cases may escape detection until adulthood. 

Criteria D: These experiences must cause suffering. To meet any diagnosis in the DSM, this is essentially a requirement. It must either “impair functioning” or cause significant distress. For this reason, there are some professionals who say that a person may be Autistic but may not meet the criteria for Autism Spectrum Condition. For example, a person may have an Autistic neurotype but experience no difficulty related to it and therefore not identify with criteria D.

Also, note that criteria D says “or in other important areas of functioning” mental health and emotional health are also areas of functioning! This language leaves it open for a clinician to consider the impact traits have on a person’s emotional and mental well-being. This is critical when assessing high-masking Autists.

Criteria E basically covers the importance of not mixing autism with intellectual disabilities. A person may struggle to pick up social cues and struggle socially due to an intellectual disability, but it isn’t autism. Intellectual disabilities and autism co-occur together at high rates, so it can be difficult (and important) to identify and sort out the differences. That is why it is important for professionals to tease out exactly what the diagnosis is and to consult the DSM-5 for other medical, genetic or environmental factors that could mask as autism or co-occur with autism.

Tip to parents: A diagnosis for autism should be done by a multidisciplinary team. A paediatrician (needs to rule out medical, metabolic and developmental conditions),  A neurologist (to evaluate brain functioning), speech and occupational therapists (focusing on speech, language, motor, sensory and developmental functioning) and psychologists/psychiatrists ( who can rule out any other mental, emotional or psychological conditions). Putting all these inputs together helps with establishing clear diagnosis.