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.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.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).Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. (American Psychiatric Association, 2013)Diagnostic Criteria for 299.00 Autism Spectrum Disorder | CDC
DSM-5 autism criteria
|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|
|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+|
|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 consists of the interpersonal aspects of autism. You need to check all 3 A criteria to get a diagnosis.Diagnostic Criteria for 299.00 Autism Spectrum Disorder | CDC
A1 asks if your social interaction is neurotypical
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 interacting 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
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 other’s 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
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 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: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 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 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|
|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.|
‘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.|
‘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.|
Summary: DSM-5 criteria for autism
Below is a quick overview of the autism criteria according to the DSM-5, in simple terms.
- A1: Differences in social initiation and responses from NTs (lack of social initiation, small talk and frequent white lies, being literal).
- A2: Challenges with expected non-verbal communication—eye contact, body language (non-intuitive), vocal (atypical volume, pitch, intonation, rate, rhythm, stress, prosody).
- A3. Atypical social relationships (more interested in special interests than people, interacting with people for utilitarian reasons rather than pleasure), challenges with social awareness (missing social cues from others indicating a change in behaviour is implicitly requested).
- B1: Stimming (tapping fingers, playing with hair, playing with a necklace, counting things).
- B2: Sameness (clothes, foods, not liking your schedule being spontaneously changed).
- B3: Special interests.
- B4: Sensory differences (hypo or hyper).
- C: Above traits appeared in childhood.
- D: Daily functioning affected by A & B.
- E: A & B not better explained by intellectual disability.