If your child has recently been diagnosed with autism spectrum disorder, or you are in the process of seeking an evaluation, you may have questions about what the autism diagnostic criteria actually requires. Autism is diagnosed against a standardized set of criteria defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM).1 In 2022, those criteria were updated. The changes are small, but intentional: they clarify what must be present for a diagnosis and give clinicians more flexibility to document the full picture of a child’s needs.
Here is what the criteria require, what changed, and what it means for families navigating a diagnosis.
What the DSM is and why it matters for autism diagnosis.
The DSM is a manual published by the American Psychiatric Association (APA).2 It is the primary tool used by healthcare professionals in the US for defining and diagnosing mental disorders. The DSM has three main sections:
- Diagnostic Classification: categorization of mental disorders
- Diagnostic Criteria: a set of symptoms and rules for qualifying a diagnosis
- Descriptive Text: additional information on symptoms, associated features, prevalence, disorder development and progression, risk factors, cultural factors, impact on daily functioning, and more
DSM-5 is the latest edition and was published in 2013. In 2022, DSM-5-TR was released, representing smaller text revisions (TR) to the fifth edition. The DSM-5-TR included changes to diagnostic criteria or definitions for over 70 disorders, including autism.3 These changes were primarily made to incorporate new data and provide clarity to certain criteria. For this reason, a text revision was published rather than a complete new edition.
What changed in the DSM-5-TR autism diagnostic criteria.
An autism diagnosis requires an individual to have persistent challenges with social communication (Criterion A) along with restricted interests and repetitive behavior (Criterion B). One of the changes made in the DSM-5-TR was to Criterion A. In the previous version, Criterion A stated an autism diagnosis required “persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following” which has since been updated to “as manifested by all of the following.” This new phrasing means that all three social communication issues must be present to reach the diagnostic threshold.
Criterion A: Social communication and interaction requirements.
All three must be present:
- Social-emotional reciprocity: challenges with back-and-forth conversation, sharing of interests or emotions, and social interactions
- Nonverbal communicative behaviors: difficulties with eye contact, body language, facial expressions, and understanding gestures
- Developing and maintaining relationships: issues with adjusting behavior for different contexts, making friends, and imaginative play4
One additional update was made to the “specifiers” section for autism. Specifiers are extensions to a diagnosis that provide information on the severity or unique features of an individual’s disorder, beyond the core criteria for diagnosis. Specifiers are useful in giving a more complete picture of an individual’s condition and can help clinicians determine more effective treatment plans.
In the previous version of the DSM, a clinician could specify if a person’s autism is “associated with another neurodevelopmental, mental or behavioral disorder.” The updated DSM-5-TR now says “associated with a neurodevelopmental, mental, or behavioral problem.” This small change in wording removes the requirement for clinicians to use diagnostic codes or diagnosed conditions as specifiers. This means they can document issues like self-injury that may not meet full disorder criteria.5
What didn’t change: DSM-5-TR Criterion B requirements.
All other aspects of the autism diagnostic criteria remain the same, including the requirements for Criterion B (restricted interests and repetitive behavior). In addition to having all three social deficits listed in Criterion A, an individual must have at least two symptoms from Criterion B.
Criterion B: Restricted interests and repetitive behaviors.
At least two of the following must be present:
- Stereotypical or repetitive movements, speech, or use of objects
- Inflexibility, difficulty coping with change
- Intense focus on specific interests or niche subjects
- Hypersensitivity to environmental sensory inputs
Why the DSM-5-TR autism criteria were updated.
Updates were made to the DSM to clarify any ambiguities and incorporate new data from research done in the years since the original 2013 publishing date. Revisions were made by a team of over 200 subject matter experts including psychiatrists, psychologists, and other health professionals.6
For the autism diagnostic criteria, the first revision was made in response to confusion around Criterion A for social communication deficits. The previous wording “manifested by the following” could be interpreted as “any of the following,” and that an individual could have only one of the social deficits to qualify. However, all three social deficits must be present for diagnosis. Changing the wording to “manifested by all of the following” clarifies this and reflects the higher diagnostic threshold required.
The second revision for autism specifiers expanded the definition so that clinicians can report other behavioral problems instead of just diagnosed disorders. Broadening this specifier can help clinicians capture a more accurate profile of a patient with autism and what unique support they may need.
What the updated criteria mean for families and clinicians.
While there are only two small changes for the autism diagnostic criteria, the revisions are meaningful. The updated text alleviates previous misunderstandings and provides a clearer picture of autism and possible co-existing behavioral problems. This clarity can help families and clinicians act quicker and with more certainty in supporting an individual who may have autism.
What the DSM-5-TR changes mean for parents.
The updated language is clearer in defining what qualifies as autism. A parent is likely the first to notice behaviors in their child that could be related to autism. Having a better understanding of what autism looks like can help parents determine if they’re seeing the same qualities in their child. This can lead to families seeking a diagnosis sooner and getting faster support.
How updated criteria help clinicians diagnose more accurately.
The updated autism diagnostic criteria are more precise and eliminate previous ambiguity, ensuring that all healthcare professionals apply the same diagnostic threshold when assessing an individual for autism. The higher threshold also reinforces that all three social communication deficits must be present, not just one. Additionally, the expanded specifier language allows clinicians to document behavioral problems that do not meet full disorder criteria, which supports a more complete clinical picture and can inform more individualized care.
When autism severity requires a higher level of care.
As autism diagnoses have become more common,7 so has the need for care options that match the full range of presentations and severity levels. For some children, the behavioral and developmental challenges associated with autism are severe enough that outpatient support is not sufficient.
For children with severe autism, a higher level of structured, hospital-based care may be the right next step. The New Directions Program at Nexus Health Systems provides structured, hospital-based care for children with severe autism and co-occurring needs. Care is coordinated across every dimension through one interdisciplinary team and one treatment plan. Services include:
- Individualized programming based on a child’s developmental level
- Medication management
- Occupational, physical, and speech-language therapies
- Therapeutic and social skills groups
Family training is built into the program so caregivers have the tools and knowledge to support their child’s progress after discharge.
Contact us to ask questions or learn more about the program. You can also learn about our Nexus Champions, patients with inspiring stories, to read about families we have supported.
