Proposed DSM5 autism diagnostic criteria made public

Below is the proposed DSM5 revision to the diagnostic criteria for autism.

Autism Spectrum Disorder

Must meet criteria A, B, C, and D:

A. Persistent deficits in social communication and social
interaction across contexts, not accounted for by general
developmental delays, and manifest by all 3 of the following:

1. 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,

2. Deficits in nonverbal communicative behaviors 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.

3. 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

B. Restricted, repetitive patterns of behavior, interests, or
activities as manifested by at least two of the following:

1. Stereotyped or repetitive speech, motor movements, or use of
objects; (such as simple motor stereotypies, echolalia, repetitive use
of objects, or idiosyncratic phrases).

2. Excessive adherence to routines, ritualized patterns of verbal
or nonverbal behavior, or excessive resistance to change; (such as
motoric rituals, insistence on same route or food, repetitive
questioning or extreme distress at small changes).

3. 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).

4. 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).

C. Symptoms must be present in early childhood (but may not become
fully manifest until social demands exceed limited capacities)

D. Symptoms together limit and impair everyday functioning.

They have also added a section discussing the rationale for the revision:

New name for category, autism spectrum disorder, which includes autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified.

* Differentiation of autism spectrum disorder from typical development and other “nonspectrum” disorders is done reliably and with validity; while distinctions among disorders have been found to be inconsistent over time, variable across sites and often associated with severity, language level or intelligence rather than features of the disorder.
* Because autism is defined by a common set of behaviors, it is best represented as a single diagnostic category that is adapted to the individual’s clinical presentation by inclusion of clinical specifiers (e.g., severity, verbal abilities and others) and associated features (e.g., known genetic disorders, epilepsy, intellectual disability and others.) A single spectrum disorder is a better reflection of the state of knowledge about pathology and clinical presentation; previously, the criteria were equivalent to trying to “cleave meatloaf at the joints”.

Three domains become two:

1) Social/communication deficits

2) Fixated interests and repetitive behaviors

* Deficits in communication and social behaviors are inseparable and more accurately considered as a single set of symptoms with contextual and environmental specificities
* Delays in language are not unique nor universal in ASD and are more accurately considered as a factor that influences the clinical symptoms of ASD, rather than defining the ASD diagnosis
* Requiring both criteria to be completely fulfilled improves specificity of diagnosis without impairing sensitivity
* Providing examples for subdomains for a range of chronological ages and language levels increases sensitivity across severity levels from mild to more severe, while maintaining specificity with just two domains
* Decision based on literature review, expert consultations, and workgroup discussions; confirmed by the results of secondary analyses of data from CPEA and STAART, University of Michigan, Simons Simplex Collection databases

Several social/communication criteria were merged and streamlined to clarify diagnostic requirements.

* In DSM-IV, multiple criteria assess same symptom and therefore carry excessive weight in making diagnosis
* Merging social and communication domains requires new approach to criteria
* Secondary data analyses were conducted on social/communication symptoms to determine most sensitive and specific clusters of symptoms and criteria descriptions for a range of ages and language levels

Requiring two symptom manifestations for repetitive behavior and fixated interests improves specificity of the criterion without significant decrements in sensitivity. The necessity for multiple sources of information including skilled clinical observation and reports from parents/caregivers/teachers is highlighted by the need to meet a higher proportion of criteria.

The presence, via clinical observation and caregiver report, of a history of fixated interests, routines or rituals and repetitive behaviors considerably increases the stability of autism spectrum diagnoses over time and the differentiation between ASD and other disorders.

Reorganization of subdomains increases clarity and continues to provide adequate sensitivity while improving specificity through provision of examples from different age ranges and language levels.

Unusual sensory behaviors are explicitly included within a sudomain of stereotyped motor and verbal behaviors, expanding the specfication of different behaviors that can be coded within this domain, with examples particularly relevant for younger children

Autism spectrum disorder is a neurodevelopmental disorder and must be present from infancy or early childhood, but may not be detected until later because of minimal social demands and support from parents or caregivers in early years.

And a “severity” scale:

Severity Level for ASD

Level 3 ‘Requiring very substantial support’

Social Communication
Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions and minimal response to social overtures from others.

Restricted interests & repetitive behaviors
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 interest or returns to it quickly.

Level 2 ‘Requiring substantial support’

Social Communication
Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from others.

Restricted interests & 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 RRB’s are interrupted; difficult to redirect from fixated interest.

Level 1 ‘Requiring support’

Social Communication
Without supports in place, deficits in social communication cause noticeable impairments. 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 interests & repetitive behaviors
Rituals and repetitive behaviors (RRB’s) cause significant interference with functioning in one or more contexts. Resists attempts by others to interrupt RRB’s or to be redirected from fixated interest.