Autism Spectrum Disorder
The impairments in communication and social interaction specified in Criterion A are pervasive and sustained. Diagnoses are most valid and reliable when
based on multiple sources of information, including clinician's observations, caregiver history, and, when possible, self-report.
The specifier "associated with a known medical or genetic condition or environmental factor" should be used when the individual has a known genetic disorder
(e.g., Rett syndrome, Fragile X syndrome, Down syndrome), a medical disorder (e.g. epilepsy), or a history of environmental exposure (e.g., valproate, fetal alcohol syndrome, very low birth weight).
Additional neurodevelopmental, mental or behavioral conditions should also be noted
(e.g., attention-deficit/hyperactivity disorder; developmental coordination disorder; disruptive behavior, impulse-control, or conduct disorders; anxiety, depressive, or bipolar disorders; tics or Tourette's disorder; self-injury; feeding, elimination, or sleep disorders).
Autism Spectrum Disorder Diagnostic Criteria 299.00 (F84.0) 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
Deficits in developing, maintaining, and understanding 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.
Autism Spectrum Disorder Diagnostic Criteria 299.00 (F84.0) 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): 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.
Autism Spectrum Disorder Diagnostic Criteria 299.00 (F84.0) 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
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.
Rett syndrome (typically between 1-4 years of age)
Disruption of social interaction may be observed during the regressive phase of Rett syndrome ; thus, a substantial proportion of affected young girls may have a presentation that meets diagnostic criteria for autism spectrum disorder. However, after this period, most individuals with Rett syndrome improve their social communication skills, and autistic features are no longer a major area of concern. Consequently, autism spectrum disorder should be considered only when all diagnostic criteria are met.
odd and repetitive behaviors and the absence of typical play become more apparent.
During the second year. Since many typically developing young children have strong preferences and enjoy repetition (e.g., eating the same foods, watching the same video multiple times), distinguishing restricted and repetitive behaviors that are diagnostic of autism spectrum disorder can be difficult in preschoolers.
Rett syndrome genetic Can't be cured, but treatment may help Requires a medical diagnosis Lab tests or imaging always required Chronic: can last for years or be lifelong
Infants seem healthy during their first six months, but over time, rapidly lose coordination, speech, and use of the hands. Symptoms may then stabilize for years.
Level 1 "Requiring support Restricted, repetitive behaviors
Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.
Level 2 "Requiring substantial support" Restricted, repetitive behaviors
Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action.
Level 3 "Requiring very substantial support" Restricted, repetitive behaviors
Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action.
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 responses to social overtures from others. For example, a person who speaks simple sentences, whose interaction is limited to narrow special interests, and who has markedly odd nonverbal communication.
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. For example, a person with few words of intelligible speech who rarely initiates interaction and, when he or she does, makes unusual approaches to meet needs only and responds to only very direct social approaches.
Level 1 "Requiring support Social communication
Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who is able to speak in full sentences and engages in communication but whose to-and-fro conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful.
A variety of nonspecific risk factors, such as
advanced parental age, low birth weight, or fetal exposure to valproate, may contribute to risk of autism spectrum disorder.
Adolescents and adults with autism spectrum disorder
are prone to anxiety and depression
Abnormalities of attention (overly focused or easily distracted) are common in individuals with autism spectrum disorder, as is hyperactivity. A diagnosis of
attention-deficit/hyperactivity disorder (ADHD) should be considered when attentional difficulties or hyperactivity exceeds that typically seen in individuals of comparable mental age.
criteria for both ADHD and autism spectrum disorder are met, both diagnoses should be given. This same principle applies to concurrent diagnoses of
autism spectrum disorder and developmental coordination disorder, anxiety disorders, depressive disorders, and other comorbid diagnoses.
diagnosis of autism spectrum disorder supersedes that of social (pragmatic) communication disorder whenever the criteria for
autism spectrum disorder are met, and care should be taken to enquire carefully regarding past or current restricted/repetitive behavior.
Hallucinations and delusions, which are defining features of schizophrenia, are not features of
autism spectrum disorder. However, clinicians must take into account the potential for individuals with autism spectrum disorder to be concrete in their interpretation of questions regarding the key features of schizophrenia (e.g., "Do you hear voices when no one is there?" "Yes [on the radio]").
In selective mutism, early development is not typically disturbed. The affected child usually exhibits appropriate communication skills in
certain contexts and settings. Even in settings where the child is mute, social reciprocity is not impaired, nor are restricted or repetitive patterns of behavior present.
Self-injury (e.g., head banging, biting the wrist) may occur, and disruptive/challenging behaviors are more common in
children and adolescents with autism spectrum disorder than other disorders, including intellectual disability.
Autism spectrum disorder encompasses disorders previously referred to as
early infantile autism, childhood autism, Kanner's autism, high-functioning autism, atypical autism, pervasive developmental disorder not otherwise specified, childhood disintegrative disorder, and Asperger's disorder.
The descriptive severity categories should not be used to determine
eligibility for and provision of services; these can only be developed at an individual level and through discussion of personal priorities and targets.
Medical conditions commonly associated with autism spectrum disorder should be noted under the "associated with a known medical or genetic condition or environmental factor" specifier. Such medical conditions include
epilepsy, sleep problems, and constipation. Avoidant/restrictive food intake disorder is a fairly frequent presenting feature of autism spectrum disorder, and extreme and narrow food preferences may persist.
For example, the report (by parents or another relative) that the individual had ordinary and sustained reciprocal
friendships and good nonverbal communication skills throughout childhood would rule out a diagnosis of autism spectrum disorder
Intellectual disability without autism spectrum disorder may be difficult to differentiate
from autism spectrum disorder in very young children.
risk period for comorbid catatonia appears to be greatest
in the adolescent years.
The behavioral features of autism spectrum disorder first become evident in early childhood, with some cases presenting a lack of interest in social interaction
in the first year of life.
Many individuals with autism spectrum disorder also have
intellectual impairment and/or language impairment (e.g., slow to talk, language comprehension behind production). Even those with average or high intelligence have an uneven profile of abilities.
Regarding the specifier "with or without accompanying intellectual impairment," understanding the (often uneven)
intellectual profile of a child or adult with autism spectrum disorder is necessary for interpreting diagnostic features. Separate estimates of verbal and nonverbal skill are necessary (e.g., using untimed nonverbal tests to assess potential strengths in individuals with limited language).
Cultural and socioeconomic factors may affect age at recognition or diagnosis; for example, in the United States,
late or underdiagnosis of autism spectrum disorder among African American children may occur
Manifestations of the social and communication impairments and restricted/repetitive behaviors that define autism spectrum disorder are clear in the developmental period. In later life, intervention or compensation, as well as current supports, may
mask these difficulties in at least some contexts. However, symptoms remain sufficient to cause current impairment in social, occupational, or other important areas of functioning.
The age and pattern of onset also should be noted for autism spectrum disorder. Symptoms are typically recognized during the second year of life (12-24 months of age) but
may be seen earlier than 12 months if developmental delays are severe, or noted later than 24 months if symptoms are more subtle.
To use the specifier "with or without accompanying language impairment," the current level of verbal functioning should be assessed and described. Examples of the specific descriptions for "with accompanying language impairment"
might include no intelligible speech (nonverbal), single words only, or phrase speech.
Motor deficits are often present, including
odd gait, clumsiness, and other abnormal motor signs (e.g., walking on tiptoes).
Some children with autism spectrum disorder experience developmental plateaus or regression, with a gradual or relatively rapid deterioration in social behaviors or use of language,
often during the first 2 years of life.
Diagnostic Features The essential features of autism spectrum disorder are
persistent (Criterion A), impairment in reciprocal social communication and social interaction and (Criterion B). restricted, repetitive patterns of behavior, interests, or activities These symptoms are present from early childhood and limit or impair everyday functioning (Criteria C and D).
The best established prognostic factors for individual outcome within autism spectrum disorder are
presence or absence of associated intellectual disability and language impairment (e.g., functional language by age 5 years is a good prognostic sign) and additional mental health problems. Epilepsy, as a comorbid diagnosis, is associated with greater intellectual disability and lower verbal ability
In adults without intellectual disabilities or language delays, deficits in social-emotional reciprocity may be most apparent in difficulties
processing and responding to complex social cues (e.g., when and how to join a conversation, what not to say).
Severity should be recorded as level of support needed for each of the two
psychopathological domains in Table (e.g., "requiring very substantial support for deficits in social communication and requiring substantial support for restricted, repetitive behaviors"). Specification of "with accompanying intellectual impairment" or "without accompanying intellectual impairment" should be recorded next. Language impairment specification should be recorded thereafter. If there is accompanying language impairment, the current level of verbal functioning should be recorded (e.g., "with accompanying language impairment—no intelligible speech" or "with accompanying language impairment—phrase speech"). If catatonia is present, record separately "catatonia associated with autism spectrum disorder."
Stereotyped or repetitive behaviors include simple motor stereotypies (e.g., hand flapping, finger flicking), repetitive use of objects (e.g., spinning coins, lining up toys), and
repetitive speech (e.g., echolalia, the delayed or immediate parroting of heard words; use of "you" when referring to self; stereotyped use of words, phrases, or prosodic patterns).
Excessive adherence to routines and restricted patterns of behavior may be manifest in
resistance to change (e.g., distress at apparently small changes, such as in packaging of a favorite food; insistence on adherence to rules; rigidity of thinking) or ritualized patterns of verbal or nonverbal behavior (e.g., repetitive questioning, pacing a perimeter).
Severity of social communication difficulties and restricted, repetitive behaviors should be
separately rated.
Among individuals who are nonverbal or have language deficits, observable signs such as changes in sleep or eating and increases in challenging behavior
should trigger an evaluation for anxiety or depression. Specific learning difficulties (literacy and numeracy) are common, as is developmental coordination disorder(Baird et al. 2011).
A diagnosis of autism spectrum disorder in an individual with intellectual disability is appropriate when social communication and interaction are
significantly impaired relative to the developmental level of the individual's nonverbal skills (e.g., fine motor skills, nonverbal problem solving). In contrast, intellectual disability is the appropriate diagnosis when there is no apparent discrepancy between the level of social-communicative skills and other intellectual skills.
When an individual shows impairment in social communication and social interactions but does not show restricted and repetitive behavior or interests, criteria for
social (pragmatic) communication disorder, instead of autism spectrum disorder, may be met.
Autism Spectrum Disorder Severity is based on
social communication impairments and restricted, repetitive patterns of behavior
First symptoms of autism spectrum disorder frequently involve delayed language development, often accompanied by lack of
social interest or unusual social interactions (e.g., pulling individuals by the hand without any attempt to look at them), odd play patterns (e.g., carrying toys around but never playing with them), and unusual communication patterns (e.g., knowing the alphabet but not responding to own name).
To use the specifier "with or without accompanying language impairment, " Language level in individuals "without accompanying language impairment" might be further described by
speaks in full sentences or has fluent speech. Since receptive language may lag behind expressive language development in autism spectrum disorder, receptive and expressive language skills should be considered separately.
Autism spectrum disorder is diagnosed four times more often in males
than in females. In clinic samples, females tend to be more likely to show accompanying intellectual disability suggesting that girls without accompanying intellectual impairments or language delays may go unrecognized, perhaps because of subtler manifestation of social and communication difficulties
Criterion A: Criterion A is now updated to read as manifested by all of the following to clarify
that all three items in Criterion A are required.
Motor stereotypies are among the diagnostic characteristics of autism spectrum disorder, so an additional diagnosis of stereotypic movement disorder is not given when such repetitive behaviors are better explained by
the presence of autism spectrum disorder. However, when stereotypies cause self-injury and become a focus of treatment, both diagnoses may be appropriate.
Autism spectrum disorder is frequently associated with intellectual impairment and structural language disorder (i.e., an inability to comprehend and construct sentences with proper grammar),
which should be noted under the relevant specifiers when applicable.
Deficits in social-emotional reciprocity (i.e., the ability to engage with others and share thoughts and feelings) are clearly evident in young children with the disorder
who may show little or no initiation of social interaction and no sharing of emotions, along with reduced or absent imitation of others' behavior. What language exists is often one-sided, lacking in social reciprocity, and used to request or label rather than to comment, share feelings, or converse
