Decoding autism in the DSM-5

Published: July 21, 2021

Last updated on October 25, 2023

Contents

1 Language in the DSM-5
2 DSM-5 criteria of autism
3 Criterion A
4 Criterion B
5 Criterion C
6 Criterion D
7 Criterion E
8 Summary: DSM-5 criteria for autism
9 References
10 Tags
11 Disclaimer

The autism criteria of the DSM-5 can be confusing, and the fact that it describes autism purely in terms of deficits causes many people to misunderstand what autism is. And because of that, even if you are autistic, the DSM description of autism may not resonate with you, and may even be the reason you rejected the possibility of being autistic.

In this post, I will explain what the autism criteria actually entail. This could give you a better understanding of what autism is and what clinicians (should) look for when assessing autism, and may help you prepare better for your upcoming autism assessment.

Language in the DSM-5

Before I discuss the autism criteria, there is something that is important to keep in mind. In defining the traits of autism, the DSM-5 uses language that is confusing, ableist, and pathology-based. This is purposeful, and works on two levels:

As the DSM is a diagnostic manual of pathologies, there is a focus on the negative symptoms of the conditions, and thus positive autistic traits are either ignored, or described as if they are negative.
But more worryingly, 70% of the board members that develop the DSM have pharmacological industry ties.^[1]DSM-5 Criticized for Financial Conflicts of Interest Many make A LOT of money through research grants and stock in the drugs used to treat the conditions described in the diagnostic manual. This had become so problematic that the National Institutes for Mental Health (NIMH)—the largest funder of the DSM—withdrew its funding support two weeks before the DSM-5 was published.

Awareness regarding this conflict of interest is crucial in understanding what your diagnosis means. And although an autism diagnosis has to be based on the DSM-5 criteria (or the criteria of a different diagnostic manual such as the ICD-10), it’s important to keep in mind that the DSM-5 does not offer a comprehensive and unbiased account of autism.

Having said that, while incomplete, the DSM-5 criteria for autism aren’t bad—it’s primarily the wording that can be problematic. When I received my diagnosis, I did not experience the negative impact some autistic people experienced after reading through their diagnostic reports.^[2]An autism diagnosis later in life | Embrace Autism I think this is largely because I had prior knowledge of the DSM’s language origins, and knew how to interpret the results.

DSM-5 criteria of autism

The DSM-5 criteria of autism consist of 10 items, divided into 2 main categories and 3 separate criteria:

Category A: Autistic social communication and social interaction.
Category B: Repetitive patterns of BehaviourS (stimming, sameness, special interests, and sensory sensitivities).
Criterion C: Symptoms must be present since Childhood.
Criterion D: Degree to which autism affects Daily functioning.
Criterion E: Traits not better Explained by intEllectual disability (or if you really want to make it fit, use Entellectual, but Martin does not like that made-up word!).

When I speak to people I assess, I explain that the DSM-5 criteria that you need to fulfill consist of 3 As, 2 Bs, and C, D & E.

I say it like this for short: 3A 2B C D & E (3æh 2bee see dee and ee). It has a nice ring to it, and I related the letters to key terms of each criterion, which makes it easy for me to remember what the criteria are. In the table below, you can see an overview of the DSM-5 autism criteria (in their words).^[3]Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. (American Psychiatric Association, 2013)^[4]Diagnostic Criteria for 299.00 Autism Spectrum Disorder | CDC

DSM-5 autism criterion A

#	Description	Required
A	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):	3/3
1	Deficits 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.	yes
2	Deficits in nonverbal communicative behaviors 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.	yes
3	Deficits in developing, maintaining, and understand relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.	yes

DSM-5 autism criterion B

#	Description	Required
B	Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):	2/4
1	Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).	2+
2	Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (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+
3	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).	2+
4	Hyper- or hyporeactivity 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).	2+

DSM-5 autism criteria C–E

#	Description	Required
C	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).	1/1
D	Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.	1/1
E	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.	1/1

Criterion A

Criterion A consists of the interpersonal aspects of autism. You need to check all 3 A criteria to get a diagnosis.^[5]Diagnostic Criteria for 299.00 Autism Spectrum Disorder | CDC

A1 asks if your social interaction is neurotypical

Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction.

You might behave differently in social settings than what is expected by society. For instance, when meeting someone for the first time, you launch into a monologue about yourself or one of your interests. Or, as an adult, you might mask but still struggle to maintain conversations built around small talk rather than in-depth discussions.

Do you like/love small talk?
Do you use small talk to indicate your class, education, income, religion, and political views without saying it directly?
Do you like being in social gatherings for extended periods?
Do you prefer speaking superficially and generally, rather than about your areas of interest?
Do you choose to hang out and socialize with people rather than interact for a purpose?

If you said NO to most of these bullet points, ya ain’t behaving like a neurotypical, and you check the boxes for autism.

A personal example:

At dinner parties in the past, I would be asked a question (part of small talk), then I would deliver a monolithic monologue. One of the most hilarious times was when I went to a dinner party with my then-husband. We went to the head of SickKids pediatric oncology. Basically, I should have been in deep reverence for this man, and should have listened rather than talked.

But…he asked me a medical question, and then kept nodding his head. Well, he seemed super interested, with his head bobbing and all, so I kept talking for about 20 minutes straight. My husband was aptly horrified.

A2 asks about differences in eye contact, voice, body language

Deficits in nonverbal communicative behaviours used for social interaction; ranging from poorly integrated verbal and nonverbal communication, through abnormalities in eye contact and body language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures.

Here we are talking about body language, facial expressions, vocal timbre, pitch, and volume. You might not like eye contact, or you might stare. You might smile or laugh at times when something makes you sad. You might have a hard time reading others’ body language and knowing what they are feeling. You may be able to, but it will be a skill you’ve acquired and not something you know intuitively.

You also might make silly voices or find that you are talking too loud or too soft. I find this out when people turn and stare at me, and my son says, ‘Mom, you are talking too loud.’

A3 asks if you have differences in your relationships

Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people.

Generally, by the time you reach adulthood, it becomes harder to make and keep friends. For example, suppose you tick A1 and A2. In that case, you will also tick A3 because if you struggle to communicate verbally and non-verbally, it will be harder to make and keep neurotypical friends.

For example, it can be tough to know when a person is a true friend and not just saying that they are a friend; or if someone is flirting with you or not.

Criterion B

Criterion B consists of the personal aspects of autism. You need to check 2 out of 4 boxes to get a diagnosis, which the DSM-5 describes as:^[9]Diagnostic Criteria for 299.00 Autism Spectrum Disorder | CDC

B1: Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).
B2: Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on the same route or food, repetitive questioning, or extreme distress at small changes).
B3: Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
B4: Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).

In non-clinical language, it’s simply asking about the following:

Stimming (tapping fingers, playing with hair, playing with a necklace, counting things).
Sameness (clothes, foods, and a dislike of last-minute schedule changes).
Special interests (we often become autodidacts or gifted artists in our chosen passion).
Sensory processing (tags, light, temperature, pain, etc.).

Criterion C

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).

Criterion C is simply about whether the traits of criteria A and B were present since childhood. Autism is lifelong, and present since/before birth.

This also means that if the observed traits were not present as a child, something other than autism may account for them.

Criterion D

Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

Criterion D is about whether your autistic traits affect your daily functioning; whether everything from criteria A and B causes clinically significant challenges in social, occupational, or other important areas of current functioning.

Based on this, there is a model of support needs, which assigns a required support level specifier for social communication and for restricted and repetitive behaviors (RRBs).

Levels of support in autism

Support level	Social communication	Restricted interests & repetitive behaviors
Level 1 ‘Requiring support’	Without supports in place, deficits in social communication cause noticeable challenges. Has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions.	Restricted and repetitive behaviors (RRBs) cause significant interference with functioning in one or more contexts. Resists attempts by others to interrupt RRBs or to be redirected from fixated interests.
Level 2 ‘Requiring substantial support’	Marked challenges in verbal and nonverbal social communication; social challenges apparent even with supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from others.	Restricted and repetitive behaviors (RRBs) and/or preoccupations or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress or frustration is apparent when RRBs are interrupted; difficult to redirect from fixated interests.
Level 3 ‘Requiring very substantial support’	Severe challenges in verbal and nonverbal social communication significantly impact daily functioning; very limited initiation of social interactions and minimal response to social overtures from others.	Preoccupations, fixated rituals and/or repetitive behaviors markedly interfere with functioning in all spheres. Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interests or returns to it quickly.

Criterion E

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.

Criteria A and B are not better explained by intellectual disability (an IQ below 70–75).^[13]What is Intellectual Disability? | APA

Summary: DSM-5 criteria for autism

Below is a quick overview of the autism criteria according to the DSM-5.

DSM-5 autism criteria

	Description	Meaning/focus
A	Challenges in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history:	Do you socialize and communicate like a neurotypical?
1	Challenges in social-emotional reciprocity (e.g. differences in social approach; failure of normal back-and-forth conversation; reduced sharing of interests, emotions, or affect; failure to initiate or respond to social interactions).	With respect to social interaction, do you respond to others in a neuronormative way?
2	Challenges in nonverbal communicative behaviors used for social interaction (e.g. poorly integrated verbal and nonverbal communication; differences in eye contact and body language or challenges in understanding and using gestures; a lack of facial expressions and nonverbal communication).	With respect to body language, do you respond to others in a neuronormative way?
3	Challenges with developing, maintaining, and understanding relationships (e.g. difficulties adjusting behavior to suit various social contexts; difficulties in sharing imaginative play or in making friends; absence of interest in peers).	Are you able to maintain relationships and adapt to social circumstances?
B	Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history:	Do you have the skills required to be a neurotypical?
1	Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).	Do you display self-soothing or self-stimulating behaviors (i.e. stimming)?
2	Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., 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).	Do you like routine and consistency, and is it challenging for you when your routine or plans unexpectedly change?
3	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).	Do you have special interests; things that you want—no, need—to know everything about?
4	Hyper- or hyporeactivity 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).	Do you find you are oversensitive to light, touch, smells, or certain textures? And do you experience any under-sensitivities?
C	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).	You have had the aforementioned traits since you were a child.
D	Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.	Your traits affect your daily life interacting in the neurotypical world.
E	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.	Do you have intellectual impairments that could better account for your traits than autism?

And the table below offers a quick summary of the criteria in simple terms.

DSM-5 autism criteria simplified

Domain	Criterion	Description	Examples
Interpersonal criteria	A1	Differences in social initiation and responses from neurotypicals.	Lack of social initiation, small talk and frequent white lies, being literal.
Interpersonal criteria	A2	Challenges with expected non-verbal communication—eye contact, (non-intuitive) body language, vocal	Atypical volume, pitch, intonation, rate, rhythm, stress, prosody.
Interpersonal criteria	A3	Atypical social relationships, challenges with social awareness (missing social cues from others indicating a change in behaviour is implicitly requested).	More interested in special interests than people, interacting with people for utilitarian reasons rather than social ones.
Personal criteria	B1	Stimming	Tapping fingers, playing with hair, playing with a necklace, counting things.
Personal criteria	B2	Sameness	Sameness in clothes and foods, and not liking your schedule being spontaneously changed.
Personal criteria	B3	Special interests	Things that you need to know everything about, and take pleasure in learning about and specializing in.
Personal criteria	B4	Sensory differences (hypo or hyper)	Sensitivity to light, aversion to certain textures, discomfort with clothing labels, sensitivity to smell; and/or less sensitivity to touch, temperature, and pain
Additional criteria	C	The above traits appeared in childhood	—
Additional criteria	D	The above traits affect daily functioning	—
Additional criteria	E	The above traits are not better explained by intellectual disability	—

References

 [+]

References
1↑	DSM-5 Criticized for Financial Conflicts of Interest
2↑	An autism diagnosis later in life \| Embrace Autism
3↑	Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. (American Psychiatric Association, 2013)
4↑, 5↑, 6↑, 7↑, 8↑, 9↑, 10↑, 11↑, 12↑	Diagnostic Criteria for 299.00 Autism Spectrum Disorder \| CDC
13↑	What is Intellectual Disability? \| APA

This article
was written by:

Dr. Natalie Engelbrecht ND RP

Dr. Natalie Engelbrecht ND RP is a dually licensed naturopathic doctor and registered psychotherapist, and a Canadian leader in trauma, PTSD, and integrative medicine strictly informed by scientific research.

She was diagnosed at 46, and her autism plays a significant role in who she is as a doctor, and how she interacts with and cares for her patients and clients.

Want to know more about her? Read her About me page.

Disclaimer

Although our content is generally well-researched
and substantiated, or based on personal experience,
note that it does not constitute medical advice.

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Decoding autism in the DSM-5

Language in the DSM-5