by Dawn Hendricks, Ph.D., Becky Boswell, M.B.A., & Alica Hart, B.A.
Defining and understanding Autism Spectrum Disorder (ASD) is a constantly evolving process. What we know now is far beyond what we once believed. Due to years of research in a wide variety of fields, our understanding of what ASD is and what it looks like in different individuals has changed dramatically over time. One way to view this progression is through the many revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association (APA). This manual is used by clinicians and researchers to diagnose and classify disorders, including ASD. The DSM 5th edition (DSM-5), released in May, 2013, provides the latest definition of ASD based on what science and research have uncovered over time.
ANSWER: It is important to remember that making a diagnosis of ASD is a complicated matter. At this time, no medical test exists for the diagnosis of ASD. Instead, making a differential diagnosis requires a clinician to gather records and information about a person’s past history, conduct observations, interview caregivers, and conduct assessments designed to aid in the identification of ASD. Such assessments are to be completed by trained medical personnel such as developmental pediatricians and psychologists.
The purpose of this fact sheet is to act as a source of information regarding the definition of ASD according to the most recent version of the DSM. It is not intended to be used in any way to identify or diagnose ASD.
ANSWER: As you can see from the timeline, both the term and the definition of Autism Spectrum Disorder have changed many times over the years. Although first defined as a mental health disorder, it was later correctly placed under neurodevelopmental disorders. The original versions provided narrow definitions, which were expanded more broadly in later years. In the earliest versions of the DSM, ASD was not well understood, and the term "autistic-type behaviors" was used. This disorder was classified with childhood schizophrenia and the label given to only those with the most severe challenges. As research and our understanding of ASD advanced, these same behaviors were classified as a separate disorder in 1980, at first called infantile autism and later changed to autistic disorder.
In 1994, with the release of the DSM-IV, the definition was modified to include the term Asperger's Syndrome for the first time. Also included at that time were the disorders Childhood Disintegrative Disorder, Rett's Syndrome, and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS). These four terms plus Autistic Disorder were grouped together under the label of Pervasive Developmental Disorder and included individuals with both severe and subtle challenges in their level and type of communication or social ability.
In this fifth edition of the DSM, as we have learned even more about the disorder, the definitions and terms have changed yet again. The terms Asperger's Syndrome, Pervasive Developmental Disorder—Not Otherwise Specified (PDD-NOS), and Childhood Disintegrative Disorder are no longer included in the definition. In addition, Rett's Syndrome is now considered a completely separate disorder. The DSM-5 will now use the overarching term Autism Spectrum Disorder and allow clinicians to indicate levels of severity. This new change reflects the idea that this disorder is a spectrum and that every individual with ASD is unique in their abilities and challenges.
ANSWER: Previously, the DSM-IV diagnostic criteria required the person to demonstrate characteristics in three categories.
ANSWER: Under the newest changes, the DSM-5 diagnostic criteria for Autism Spectrum Disorder require the person to demonstrate characteristics in two categories.
For a person to meet criteria, characteristics must be present during a child’s early development. However, the characteristics may not become evident until the child is older and is placed in social situations that exceed his or her social abilities.
ANSWER: New to the definition of ASD, clinicians now rate a person who meets the criteria for ASD according to Level of Severity. Clinicians are to determine the severity of characteristics. The levels include:
ANSWER: As you can see, there have many changes to the diagnostic criteria! Communication and social deficits have been grouped together because they often overlap. Under the DSM-IV, language delay was a very important diagnostic piece; however, under the DSM-5, a language delay will no longer be considered a part of the diagnosis.
Another important difference includes the changes to the criteria regarding restricted and repetitive behaviors. New is the inclusion of hyper- or hyporeactivity to sensory input. Sensory differences have long been recognized as a challenge for many individuals with ASD and are now recognized as part of the official diagnostic criteria.
ANSWER: In the past few decades, we have learned a tremendous amount of information about ASD. As we have learned more facts about the disorder, it was necessary to update the definition to reflect current knowledge. Additionally, as many professionals and families can attest, accurately diagnosing ASD is not easy. Despite the existence of many excellent diagnostic evaluations, the diagnosis of ASD is a subjective process and often relies on the examiner's ability to interpret behavior. Because observation can lead to a variety of opinions about what a behavior 'looks' like, it is very easy to find several professionals who disagree on an ultimate diagnosis. The definition for ASD in the DSM-5 has been revised in the hopes of providing clear criteria, which will result in simplifying the process of providing an accurate diagnosis.
ANSWER: Anyone diagnosed with any of the four disorders from the DSM-IV should still meet the criteria for ASD in the DSM-5, or be found to have another, more accurate, DSM-5 diagnosis. According to the DSM-5: "Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive development disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication but whose symptoms do not otherwise meet criteria for autism spectrum disorder should be evaluated for social communication disorder (SCD)." (American Psychiatric Association, 2013, p. 51).
Individuals with a long-standing diagnosis, therefore, may continue to carry the new ASD diagnosis. As noted above, the DSM-5 also includes a new communication disorder called Social Communication Disorder, or SCD. Even though the definitions of ASD and SCD share similar social communication deficits, the difference is that the criteria for ASD includes restricted and repetitive behaviors, interests, and activities.
ANSWER: Many individuals with ASD, their families, and the professionals who support them have expressed concerns over identification and eligibility within the school system and what the DSM-5 might mean for special education services. According to the Virginia Department of Education, the Virginia Regulations Governing Special Education Programs for Children with Disabilities (2010) contain specific eligibility criteria for "autism" and other disabilities and are not impacted by the changes in the DSM-5. It is important to remember that medical diagnosis and educational eligibility are different. The changes to the definition provided in the DSM-5 will change the criteria a person needs to meet in order to receive a medical diagnosis. However, the DSM-5 will not change the criteria a person needs to meet for Educational Identification. Individuals with autism who are in the public school system and are in need of special education services will still need to meet the criteria for "autism" outlined in the Virginia regulations.
For more information about the DSM-5 and the definition of ASD, please refer to the APA Factsheet: http://www.dsm5.org/Documents/Autism%20Spectrum%20Disorder%20Fact%20Sheet.pdf
For more information on the American Psychiatric Association and/or to purchase a copy of the DSM-5, please visit the APA website: http://www.psych.org/
Please visit the VDOE website for additional information on evaluation and eligibility in the Special Education process. http://www.doe.virginia.gov/special_ed/tech_asst_prof_dev/topic_specific_resources/index.shtml
For additional information on VCU-ACE please go to our website: www.vcuautismcenter.org
Contributors for this issue: Dawn Hendricks, Ph.D., Becky Boswell, M.B.A., & Alica Hart, B.A.
Editor: Becky Boswell, M.B.A.
Information for this Frequently Asked Questions (FAQ) is from Virginia Commonwealth University's Autism Center for Excellence (VCU-ACE), which is funded by the Virginia State Department of Education (Grant # 881-61172-H027A100107). Virginia Commonwealth University is an equal opportunity/affirmative action institution providing access to education and employment without regard to age, race, color, national origin, gender, religion, sexual orientation, veteran’s status, political affiliation, or disability. If special accommodations or language translation are needed contact Voice (804) 828-1851 | TTY (804) 828-2494.