AUTISM SPECTRUM DISORDER

Autism Spectrum Disorder and the Changes Made Within the DSM-5

Hannah Haskin

University of South Carolina

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The current criteria for diagnosing autism spectrum disorder (ASD) can be found within

the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders

(2013). The fifth edition of this manual is the most recent having been published in 2013, with

the changes made from the fourth to the fifth edition came a lot of controversy and debate which

sparked further research within the field (Mazurek et al., 2017). As stated in the DSM 5,

characteristics of autism spectrum disorder are diagnosed through use of five different criterion.

The first criterion, Criterion A, for diagnosis of ASD is the lack of reciprocal communication and

social interaction. Criterion B addresses the regulated and rhythmic patterns of behavior,

interests, or occupations. Furthermore, Criterion C and D state that ASD symptoms must have

existed since early development and must pose significant impairment. Lastly, Criterion E states

that these symptoms must not be better attributed to intellectual developmental disorder or global

developmental delay; they may also be symptoms characteristic of comorbid diagnoses

(Association, 2013).

As stated through diagnostic Criterion A, impairment with conversational speech is a

huge indicator for diagnosis of ASD. For example, an individual with ASD might only exhibit

abnormal sounds, meaningless speech, echolalia or neologisms. The abnormal sounds or

meaningless speech are characteristic of individuals with ASD but must be accompanied with

significant impairment to aid in diagnosis of ASD. Echolalia, or the echo-ing of others speech, is

a key marker for individuals with ASD. This usually is impairing in that it effects the individuals

ability to hold out a conversation. Other typical impairments of verbal communication are, but

not limited to, excessive questioning, difficulty understanding jokes, and restricted topics of

conversation. It is also important to note if these symptoms are persistent, meaning lasting past
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three years of age, because these speech patterns could be seen in typical or delayed development

as well (Mukherjee, 2017).

As for Criterion B, the main concern is impairment with behavior and behavioral

patterns. These behaviors can be exhibited in many ways and become increasingly impairing

with the frequency and repetitiveness of the actions and the level of distress that may be

provoked by the stopping of the action. Some of these actions present themselves through

rocking, twirling, hand flapping, or banging of objects. Another atypical behavioral pattern of

those with ASD is preoccupation for unusual objects. Those with ASD might also have difficulty

transitioning and may not be able to function well without a set schedule or routine (Mukherjee,

2017).

As stated in Criterion E, it is important to specify if there are any diagnoses that could be

better attributed to the symptoms or the possible comorbidity of the symptoms. Possible

comorbid diagnoses for ASD are as follows: cognitive impairment, epilepsy, psychiatric

illnesses, feeding disturbances, gastrointestinal illnesses, sleep disturbances, and dimorphism.

The comorbid diagnosis of cognitive impairment is reported in 50-70% of individuals with ASD,

the diagnosis of this primarily being based on the non-verbal based skills of the individual.

Epilepsy is seen in 25-30% of individuals with ASD and is seen primarily through both infancy

and adulthood. The comorbid diagnosis of psychiatric illnesses are diagnoses of ADHD,

depression, anxiety, and OCD. Of which, these diagnoses are most likely a result of the ASD

diagnosis being a precursor. Feeding disturbances is another common comorbid condition and is

characterized through poor food acceptance, decreased food chewing, and food aversions and

selectivity. GI illness is a frequent comorbid diagnosis that presents itself through vomiting,

reflux, and complaints of stomach pain. Sleep disturbances are characterized through the
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difficulty of those with ASD falling asleep and staying asleep. Lastly, dymorphism is observed in

18-20% of those with ASD (Mukherjee, 2017).

Along with the five criterion noted within the DSM-5 that are used to diagnose ASD,

there are also specifiers that are used to describe the severity to which an individual is affected

with ASD. There are three levels used to specify the severity, with level one being the least to

level three being the most. The severity for Criterion A and B is noted and then used to

categorize the individual into one of the three levels of severity. It is important that the

individual’s severity is categorized separately; severity of communication impairment (A) should

be rated distinctly from severity of behavioral impairment (B). Individuals with level one

severity are described as “requiring support”. Those with level two are described as “requiring

substantial support”. Lastly, those considered to be on the highest, or third, level of severity are

described as “requiring very substantial support”. The DSM-5 also states that a handful of other

specifiers should be noted. It is important to specify if the ASD is with or without the following

in accompaniment: intellectual impairment, language impairment, known medical or genetic

condition or environmental factor, another neurodevelopmental, mental or behavioral disorder,

and catatonia (Association, 2013).

It is imperative that individuals meet the criteria of needing to have the symptoms of

ASD occur beginning in early development. If onset of these symptoms is later in life it is crucial

to determine if these symptoms were not yet noticeable due to a possible underlying cause or if

the symptoms are attributed to an alternative diagnosis. In addition to the onset of the symptoms

it is also important to note the extent of impairment to which these symptoms cause. To meet the

criteria for ASD, the symptoms must cause impairment on activities and tasks that are common

within that level of development (Association, 2013).

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The developmental nature of this diagnosis varies from individual to individual. While

the diagnostic criteria states that symptoms must be present from early development there is the

possibility that the symptoms may diminish over time while there is also a possibility that

symptoms may be impairing throughout the entirety of the individuals life. With a spike in ASD

diagnosis in the 70s, there is an increasing number of individuals with ASD that are aging. With

this growing population has come more research. Results of a study published in 2017 found

three main areas of concern within the aging ASD population. Training needs was the first theme

identified. This encompassed the perceived lack of knowledge of those caring for individuals

with ASD. Many individuals’ families posed this need for training due to concern of what their

child/family member’s life will be like once the family members are passed. Another theme

identified in this study was concerns within community engagement and socialization. Many

adult individuals with ASD expressed issues making friends and becoming engaged within their

community. One individual expressed feeling that there was in fact enough support to aid in this

area such as autism support groups; however, many individuals expressed feeling as though there

is a gap that needs to be bridged. There are also barriers that have been identified in employment

of adults with ASD. Some individuals expressed being able to find jobs while many others found

it difficult to obtain and maintain employment. In conclusion, this study found that there needs to

be more education of those caring for individuals with ASD and also more education for the

general community on autism so that individuals with ASD can be better understood (Koffer

Miller, Mathew, Nonnemacher, & Shea, 2017).

The most recent data on autism spectrum disorder diagnoses states that across both US

and non US countries, statistics have risen to about 1% of the population having such diagnosis.

This rise in the number of individuals with ASD may be attributed to the expansion of the
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criteria used to diagnose ASD in the DSM IV. In the late 1900s, there was much debate on

whether the rise in individuals with ASD was attributed to the administration of the MMR

vaccine (Madsen & Vestergaard, 2004). Since this controversy was brought about many studies

have been made upon whether or not there is a correlation. It was found that there is no causal

relationship between ASD and MMR vaccine, so the Wakefield hypothesis has since been

retracted (Wakefield et al., 1998). With the retraction of this also came more research on

potential risk factors for ASD.

Risk factors for ASD can be separated into two categories: genetic and environmental

risk factors. For environmental risk factors there are a few nonspecific factors stated within the

DSM-5 such as parental age being high, low birth weight, and fetal exposure to substances.

While genetics seems to play a role in some cases of ASD, currently there is only a 15%

association factor of genetics. With that being said the remaining risk factors for ASD may be

found within several hundreds of genes possibly contributing in small ways that work together

present ASD symptoms (Association, 2013).

With the most recent edition of the DSM came many changes to the diagnostic criteria

for ASD (Grzadzinski, Huerta, & Lord, 2013). The previous edition, DSM IV, included a

variety of other disorders that are all now encompassed within the ASD diagnosis. Diagnoses

such as early infantile autism, Kanner’s autism, high functioning autism, atypical autism,

pervasive developmental disorder not otherwise specified, childhood disintegrative disorder and

Asperger’s disorder were all eliminated in the DSM-5 and as long as criteria was still met for

ASD individuals are now considered to have ASD. Those with significant deficits but not

significant enough to meet ASD diagnosis should be evaluated for social communication

disorder, SCD (Association, 2013).

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The eliminating of such subcategories has allowed for a broader diagnosis of ASD while

also allowing for more specificity with use of a new diagnosis, SCD, for individuals who don’t

meet the criteria for diagnosis of ASD. A study published in 2012 which compared the

sensitivity and specificity of the proposed DSM-5 to the DSM IV found that only 60.6% of

individuals previously diagnosed with ASD met the new criteria stated within the proposed

DSM-5. These results were found through use of field trial symptom checklists within a study

sample of 933 participants, of which 657 met DSM-IV criteria for diagnosis of ASD. The

findings of this study were mainly used to shed light on the number of individuals that were

concerned with being affected by this change in diagnostic criteria. There was much controversy

over the potential issues that the DSM-5 would have on those previously diagnosed with ASD

that would no longer meet criteria. The main area of concern that came with this was the worry

of eligibility of services for those that would no longer meet criteria (McPartland, Reichow, &

Volkmar, 2012).

Intervention based treatments are very important for individuals with ASD that are still

developing, being one of the reasons why there was so much concern on no longer meeting

criteria for diagnosis with the DSM-5 criteria. If criteria was no longer met, individuals that were

believed to need intervention may no longer be eligible for intervention services. A lot of current

interventions are based around behavior of the individual and learning adaptive strategies for

communication (Mukherjee, 2017).

In conclusion, the diagnosis of autism spectrum disorder is vast and there are many areas

to take into account when considering diagnosis of ASD. There is a lot of further research to be

done in this field to get to a place where all individuals with this diagnosis can participate in
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normal activities without impairment. Future studies might include more evidence based

interventions or more specific risk factors associated with ASD.

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References

Association, A. P. (2013). DSM 5. American Journal of Psychiatry.

https://doi.org/10.1176/appi.books.9780890425596.744053

Grzadzinski, R., Huerta, M., & Lord, C. (2013). DSM-5 and autism spectrum disorders (ASDs):

an opportunity for identifying ASD subtypes. Molecular Autism, 4(1), 12.

https://doi.org/10.1186/2040-2392-4-12

Koffer Miller, K. H., Mathew, M., Nonnemacher, S. L., & Shea, L. L. (2017). Program

experiences of adults with autism, their families, and providers: Findings from a focus

group study. Autism, 136236131667900. https://doi.org/10.1177/1362361316679000

Madsen, K. M., & Vestergaard, M. (2004). MMR vaccination and autism: What is the evidence

for a causal association? Drug Safety. https://doi.org/10.2165/00002018-200427120-00001

Mazurek, M. O., Lu, F., Symecko, H., Butter, E., Bing, N. M., Hundley, R. J., … Handen, B. L.

(2017). A Prospective Study of the Concordance of DSM-IV and DSM-5 Diagnostic

Criteria for Autism Spectrum Disorder. Journal of Autism and Developmental Disorders,

47(9), 2783–2794. https://doi.org/10.1007/s10803-017-3200-7

McPartland, J. C., Reichow, B., & Volkmar, F. R. (2012). Sensitivity and specificity of proposed

DSM-5 diagnostic criteria for autism spectrum disorder. Journal of the American Academy

of Child and Adolescent Psychiatry, 51(4), 368–383.

https://doi.org/10.1016/j.jaac.2012.01.007

Mukherjee, S. B. (2017). Autism Spectrum Disorders — Diagnosis and Management. Indian

Journal of Pediatrics, 84(4), 307–314. https://doi.org/10.1007/s12098-016-2272-2

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Wakefield, A., Murch, S., Anthony, A., Linnell, J., Casson, D., Malik, M., … Walker-Smith, J.

(1998). RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and

pervasive developmental disorder in children. The Lancet, 351(9103), 637–641.

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