DSM­5 AUTISM SPECTRUM DISORDER GUIDELINES & CRITERIA EXEMPLARS eneral Guidelines • One example of a specific criterion may not be sufficient to assign the criterion as being present. o Is the example behavior clearly atypical? o Is the example behavior present across multiple contexts? o Distinguish between behaviors that are clearly atypical and present across multiple contexts, versus behaviors that are on the borderline of being atypical or rarely occur/occur in only one context. For example, while toe walking may be an example of criterion B1, it may not be sufficient by itself to assign the criterion if there is a physical explanation for the behavior (and thus not clearly atypical) and/or if it occurs only in one context (e.g. at the beach when barefoot in the sand). By contrast, a preoccupation with lawnmowers that involves obsessively drawing lawnmowers, seeking out lawnmowers, and talking about lawnmowers is sufficient to meet criterion B3 even if no other examples exist. This preoccupation is clearly atypical and is present across multiple contexts. • Avoid using the exact same behavioral exemplar to satisfy two criteria. o Some behaviors may appear to satisfy multiple DSM‐5 criteria. It is the responsibility of the clinician to decide where the behavior is best represented. For example, ‘repetitively putting hands over ears’ may satisfy B1 because it is a repetitive motor movement, or it may be considered under B4 because it represents an adverse reaction to sounds. o Some behaviors are multi‐faceted and may satisfy multiple DSM‐5 criteria. For example, a child who is obsessed with string and insists on always carrying string with him at all times may meet criteria for B3 due to a strong attachment to an unusual object. If the same child also frequently waves string in front of his face and watches it flop up and down, then B4 should also be considered due to the visual sensory aspect of this behavior. • Behaviors that are not currently present may be considered. o A behavior that only occurred in the past may be sufficient to assign a criterion. o It is important to consider whether a behavior that occurred in the past is atypical for developmental norms (e.g. handflapping should not be counted if it only occurred from 6‐9 months of age). • Everything is subject to change. o The final publication of the DSM‐5 (May 2013) may provide more guidance on the number of behavioral exemplars required. o The number of required criteria may change. o Major changes possible…. SM‐5 Criteria for ASD With Examples G D
A. PERSISTENT DEFICITS IN SOCIAL COMMUNICATION AND SOCIAL INTERACTION ACROSS CONTEXTS, NOT ACCOUNTED FOR BY GENERAL DEVELOPMENTAL DELAYS , AND MANIFEST BY 3 OF 3 SYMPTOMS: A1. 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. • Abnormal social approach o Unusual social initiations (e.g. intrusive touching; licking of others) Laura Carpenter, PhD February 2013 •
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o Use of others as tools A1 reflects problems with Failure of normal back and forth conversation o Poor pragmatic/social use of language (e.g. social initiation and response does not clarify if not understood; does not provide background information) o Failure to respond when name called or when spoken directly to o Does not initiate conversation o One‐sided conversations/monologues/tangential speech Reduced sharing of interests o Doesn’t share o Lack of showing, bringing, or pointing out objects of interest to other people o Impairments in joint attention (both initiating and responding) Reduced sharing of emotions/affect o Lack of responsive social smile (note: the focus here is on the response to another person’s smile; other aspects of emotional expression should be considered under A2). o Failure to share enjoyment, excitement, or achievements with others o Failure to respond to praise o Does not show pleasure in social interactions o Failure to offer comfort to others o Indifference/aversion to physical contact and affection Lack of initiation of social interaction o Only initiates to get help; limited social initiations Poor social imitation o Failure to engage in simple social games A2. 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. • Impairments in social use of eye contact • Impairment in the use and understanding of body A2 reflects problems with non­
postures (e.g. facing away from a listener) verbal communication • Impairment in the use and understanding of gestures (e.g. pointing, waving, nodding/shaking head) • Abnormal volume, pitch, intonation, rate, rhythm, stress, prosody or volume in speech • Abnormalities in use and understanding of affect (note: responsive social smile should be considered under A1, while affect that is inappropriate for the context should be considered under A3) o Impairment in the use of facial expressions (may be limited or exaggerated) o Lack of warm, joyful expressions directed at others o Limited communication of own affect (inability to convey a range of emotions via words, expressions, tone of voice, gestures) o Inability to recognize or interpret other’s nonverbal expressions • Lack of coordinated verbal and nonverbal communication (e.g. inability to coordinate eye contact or body language with words) • Lack of coordinated non‐verbal communication (e.g. inability to coordinate eye contact with gestures) A3. 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 • Deficits in developing and maintaining relationships, appropriate to developmental level ‐ Lack of “theory of mind”; inability to take another person’s perspective (CA ≥ 4 years) Laura Carpenter, PhD February 2013 •
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Difficulties adjusting behavior to suit social contexts ‐ Does not notice another person’s lack of interest in an activity ‐ lack of response to contextual cues (e.g. social cues from others indicating a change in behavior is implicitly requested) ‐ Inappropriate expressions of emotion (laughing or smiling out of context) (note: other abnormalities in the use and understanding of emotion should be considered under A2) ‐ Unaware of social conventions/appropriate social behavior; asks socially inappropriate questions or makes socially inappropriate statements ‐ Does not notice another’s distress or disinterest ‐ Does not recognize when not welcome in a play or conversational setting ‐ Limited recognition of social emotions (does not notice when he or she is being teased; does not notice how his or her behavior impacts others emotionally) Difficulties in sharing imaginative play (Note: solitary imaginative play/role playing is NOT captured here) ‐ Lack of imaginative play with peers, including social role playing (>4 years developmental age) Difficulties in making friends ‐ Does not try to establish friendships ‐ Does not have preferred friends ‐ Lack of cooperative play (over 24 months developmental age); parallel play only ‐ Unaware of being teased or ridiculed by other children ‐ Does not play in groups of children ‐ Does not play with children his/her age or developmental level (only older/younger) ‐ Has an interest in friendship but lacks understanding of the conventions of social interaction (e.g extremely directive or rigid; overly passive) ‐ Does not respond to the social approaches of other children Absence of interest in others ‐ Lack of interest in peers ‐ Withdrawn; aloof; in own world A3 reflects problems with ‐ Does not try to attract the attention of others ‐ Limited interest in others; social awareness and insight, ‐ Unaware or oblivious to children or adults as well as with the broader ‐ Limited interaction with others ‐ Prefers solitary activities concept of social relationships
B. RESTRICTED, REPETITIVE PATTERNS OF BEHAVIOR, INTERESTS, OR ACTIVITIES AS MANIFESTED BY AT LEAST 2 OF 4 SYMPTOMS: B1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases). • Stereotyped or repetitive speech o Pedantic speech or unusually formal language (child speaks like an adult or “little professor”) B1 includes atypical speech, o Echolalia (immediate or delayed); may include repetition of words, phrases, or more extensive movements, and play songs or dialog o “Jargon” or gibberish (mature jargoning after developmental age of 24 months) o Use of “rote” language o Idiosyncratic or metaphorical language (language that has meaning only to those familiar with the individual’s communication style); neologisms o Pronoun reversal (for example, “You” for “I”; not just mixing up gender pronouns) o Refers to self by own name (does not use “I”) o Perservative language (note: for perseveration on a specific topic, consider B3) Laura Carpenter, PhD February 2013 Repetitive vocalizations such as repetitive B3 includes preoccupations guttural sounds, intonational noise‐making, unusual squealing, repetitive humming with objects or topics Stereotyped or repetitive motor movements o Repetitive hand movements (e.g., clapping, finger flicking, flapping, twisting) o Stereotyped or complex whole body movements (e.g., foot to foot rocking, dipping, & swaying; spinning) o Abnormalities of posture (e.g., toe walking; full body posturing) o Intense body tensing o Unusual facial grimacing o Excessive teeth grinding o Repetitively puts hands over ears (note: if response to sounds, consider B4) o Perseverative or repetitive action / play / behavior (note: if 2 or more components, then it is a routine and should be considered under B2) o Repetitive picking (unless clear tactile sensory component, then consider B4) Stereotyped or repetitive use of objects o Nonfunctional play with objects (waving sticks; dropping items) o Lines up toys or objects o Repetitively opens and closes doors o Repetitively turns lights on and off o
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B2. 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). • Adherence to routine o Routines: specific, unusual multiple‐step sequences of behavior B2 includes rituals and o Insistence on rigidly following specific resistance to change routines (note: exclude bedtime routines unless components or level of adherence is atypical) o Unusual routines • Ritualized Patterns of Verbal and Nonverbal Behavior o Repetitive questioning about a particular topic (distinguish from saying the same word or phrase over and over, which goes under B1) o Verbal rituals ‐ has to say one or more things in a specific way or requires others to say things or answer questions in a specific way o Compulsions (e.g. insistence on turning in a circle three times before entering a room) (note: repetitive use of objects,, including lining up toys, should be considered under B1). • Excessive resistance to change o Difficulty with transitions (should be out of the range of what is typical for children of that developmental level) o Overreaction to trivial changes (moving items at the dinner table or driving an alternate route) • Rigid thinking o Inability to understand humor o Inability to understand nonliteral aspects of speech such as irony or implied meaning o Excessively rigid, inflexible, or rule‐bound in behavior or thought 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). • Note: Consider B1 for perservative speech Laura Carpenter, PhD February 2013 •
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Preoccupations; obsessions Interests that are abnormal in intensity Narrow range of interests Focused on the same few objects, topics or activities Preoccupation with numbers, letters, symbols Being overly perfectionistic Interests that are abnormal in focus Excessive focus on nonrelevant or nonfunctional parts of objects Preoccupations (e.g. color; time tables; historical events; etc) Attachment to unusual inanimate object (e.g., piece of string or rubber band) Having to carry around or hold specific or unusual objects (not common attachment objects such as blankets, stuffed animals, etc.) Unusual fears (e.g. afraid of people wearing earrings) •
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). • High tolerance for pain • Poking own eyes • Preoccupation with texture or touch (includes attraction/aversion to texture) o Tactile defensiveness; does not like to be touched by certain objects or textures o Significant aversion to having hair or toenails cut, or teeth brushed • Unusual visual exploration / activity o Close visual inspection of objects or self for no clear purpose (for example, holding things at unusual angels) (no vision impairment) o Looks at objects, people out of corner of eye o Unusual squinting of eyes B4 includes atypical sensory o Extreme interest or fascination with watching movement of other things (e.g., the spinning behaviors wheels of toys, the opening and closing of doors, electric fan or other rapidly revolving object) • In all domains of sensory stimuli (sound, smell, taste, vestibular, visual), consider: o Odd responses to sensory input (e.g. becoming extremely distressed by the atypical sound) o Atypical and/or persistent focus on sensory input • Unusual sensory exploration with objects (sound, smell, taste, vestibular) o Licking or sniffing objects (note: as part of a ritual, consider B2; licking or sniffing people consider A1) C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities) •
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Early primary caregiver report no longer essential “Early Childhood” approximately age 8 and younger (flexible) D. Symptoms together limit and impair everyday functioning. Laura Carpenter, PhD February 2013 •
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Select one severity level specifier for Social Communication and one for Restricted Interests and Repetitive Behaviors. Minimal social impairments: “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.” (from DSM 5 severity rating) Minimal RRB impairments: “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.” (from DSM 5 severity rating) Severity Level for ASD Level 3 ‘Requiring very substantial support’ Level 2 ‘Requiring substantial support’ Level 1 ‘Requiring support’ Social Communication Restricted Interests & Repetitive Behaviors 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. 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. 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. 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. 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. 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. Laura Carpenter, PhD February 2013 Behaviors/symptoms that are not/may not be captured in DSM‐5 ASD • Problems with play/imagination o Impairments in imaginative/symbolic play o Lack of functional play skills o Difficulty distinguishing fantasy from reality • Shyness/social anxiety • Language and developmental delays o Milestone delays/developmental delays o Speech delays (expressive or receptive) o Language disorder • Behavioral difficulties/temper tantrums • Poor imitation skills (poor SOCIAL imitation skills ARE captured) Author: Laura Carpenter, PhD BCBA Associate Professor of Pediatrics Medical University of South Carolina carpentl@musc.edu Acknowledgements: Dr. Catherine Rice and others associated with the CDC ADDM (Centers for Disease Control and Prevention Autism and Developmental Disabilities Monitoring) project developed the broader list of exemplars from which these exemplars were adapted. Dr. Rice, Dr. Catherine Cheely, and Dr. Catherine Lord collaborated with Dr. Carpenter in the categorization of behaviors relative to DSM 5 criteria. However, any errors or misinterpretations are Dr. Carpenter’s responsibility. Laura Carpenter, PhD February 2013