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Autism in Plain English: The DSM-IV-TR Criteria Explained
 The mental health bible used by professionals for diagnosing autism spectrum disorders in children is the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition, Text Revision (shortened to DSM-IV-TR).
This plain English interpretation of the DSM-IV-TR criteria for autism is not a diagnostic tool. It was written to help you better understand the constellation of symptoms that comprise autism. The 943-page DSM-IV-TR, published in 1994 by American Psychiatric Publishing Inc., lists 297 disorders and is set for revision in 2111. The DSM first recognized autism as a disorder during the same year Ronald Reagan was elected president — 1980.
The pervasive developmental disorders (PDD) heading in the DSM-IV-TR lists the diagnostic criteria for the five autistic or autism spectrum disorders. They include Autism, Childhood Disintegrative Disorder, Asperger Syndrome, Rett Syndrome, and pervasive developmental disorder-not otherwise specified, or PDD-NOS. Each of the PDD disorders has their own code and symptoms. For example, the diagnosis code for “autistic disorder” is 299. PDD is not a specific disorder; it only refers to the category that all of the disorders fall under.
An autism diagnosis is based on a set of well-defined criteria as outlined in the DSM-IV-TR. To determine whether a child fulfills the criteria, professionals will:
 Observe your child;
Interview you; and
Test your child using various tools, or “protocols,” as professionals call them. The ADOS (Autism Diagnostic Observation Scale) is considered the “gold standard” tool for diagnosing autism spectrum disorders. Another popular tool is the CARS (Childhood Autism Rating Scale), but this tool is less comprehensive. The ADOS involves two half days of testing and is more precise than the CARS, which is a rating scale that lumps children into three categories: non-autistic, autistic and severely autistic.
Your child is likely to undergo other tests that measure intelligence and communication skills. A “multidisciplinary” team conducts these tests. A multidisciplinary team involves a group of doctors and other professionals who are experts in different specialties, called “disciplines.” Despite their different areas of expertise, they work together to find out what’s wrong with your child.
How a Diagnosis Is Made
For a child to meet the diagnostic criteria, doctors look at three broad categories: social interaction, communication and behavior. Each category lists a specific set of symptoms. There are 12 symptoms all together.
To receive a diagnosis of “autistic disorder,” a child must have at least six of the 12 symptoms, but they need to be spread out among the three categories in a certain way.
The social interaction category, for example, lists four symptoms, and at least two must be present. Under communication, one symptom is necessary. The same holds true for the behavior category. Add that up, and you get four of the six symptoms. The other two symptoms can come from any of the three categories — meaning they could come from just one category or distributed over two.
The DSM-IV-TR criteria for autism can be difficult for the layperson to understand. Moreover, not all children show the same symptoms every day, and the intensity and severity of symptoms will differ from child to child.
The Three Core Symptoms
The first category identifies deficits in the way a child relates to others without using words. It involves body language, such as gestures, body posture, expressions and other mannerisms that send a message. "Nonverbal" communication, as it is called, often complements the spoken word but not always.
While body language in babies and toddlers is obviously not as sophisticated as it is in adults, very young children communicate with their bodies. They may look away from you based on your facial expression, point at something, or return a smile.
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Social | Your child needs to have at least two of the following four symptoms from the social category.
1. Problems developing a range of nonverbal behaviors.
Examples: Babies who struggle to make eye contact or don't return big smiles by six months are at-risk.
2. Problems developing peer relationships that would be appropriate for a child’s developmental level.
Examples: How children make friends develops along a generally predictable sequence of milestones. First, babies engage in solitary play to entertain themselves. At around 2 to 3 years old, parallel play — playing near but not with another child—emerges. Parallel play acts as a critical bridge to the next level of play, which is a child seeking to join in cooperative play with other children. At-risk children avoid the company of their peers by being “off by themselves.” They don’t imitate the actions of other children or approach them. Depending on the severity, this symptom can be very difficult to diagnose in children under 2 years old.
3. Fails to seek attention to share interests, achievements or pleasure with other people.
Examples: Typically developing children spontaneously draw your attention to show you an accomplishment — a picture they’ve drawn — or share in other simple pleasures by pointing or bringing you something. Look for an absence in seeking to share.
4. Fails to respond to social and emotional cues. This is known as social and emotional reciprocity.
Examples: Children who lack social and emotional reciprocity don’t greet others or wave hello and goodbye. They also don’t get excited about opening presents or seeing their parents after they’ve come home from work. They don’t understand the feelings of others and wouldn’t, for example, know how to show concern for another child with a scraped knee. Children with these deficits also don’t seek the company of their peers, and parents don’t feel their child engages with them.
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Communication |
Your child needs to have at least one of the following four symptoms.
1. Delay or absence of speech with no attempt to compensate by using gestures.
Examples: Children at-risk for autism don’t point to what they want, shake their head to indicate “no” or nod for “yes.” They also don’t “mime” their needs.
2. If speech develops, a child will not be able to start or carry on a conversation.
Examples: Speech that is spontaneous is key. Many children with autism cannot initiate a conversation.
3. It is not uncommon for children with autism to parrot phrases that come from books, videos, music or another person.
Examples: When a child parrots, or “echoes,” what he’s heard, it is called echolalia (echo-lay-leah). As typically developing children learn to talk, they also repeat things they’ve heard, but this skill drops off fairly rapidly as they learn to express needs by creating novel sentences using a noun and a verb. Although echolalia is a symptom of autism and can sound odd, it is considered a positive prognostic sign for future language development.
4. No pretend play.
Example: A child does not use his imagination when he rolls the wheels of a train back and forth or spins them. But taking the same train and picking up passengers at a make-believe station and dropping them off at a park is.
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Behavior |
The last category involves behaviors. Think of a child who resists change at all costs, repeats a behavior over and over, or becomes preoccupied with the parts of an object.
A child must have one of the following four symptoms:
1. An interest or action of intense or abnormal focus.
Examples: Children with autism have limited interests. A child may fixate on a particular toy character, such as Thomas the Tank, or watch the same video or TV show so many times that it becomes disturbing.
2. Rigidly follows a routine or ritual that has no purpose.
Examples: Many children with autism insist on sticking to the same routine or ritual, such as lining up cars in the same order or insisting on the same route to the grocery store. Changing the order of the cars or taking a different route could spark a tantrum.
3. Repetition of particular movements or gestures.
Examples: Most children with autism engage in purposeless movements — hand flapping, clapping, rocking, pacing, toe walking, twirling, chewing on clothing. These self-stimulatory behaviors, or "stims," inhibit children from pursing other play activities. Clinicians describe these motor mannerisms as "stereotypic" because they are inappropriate, persistent and repetitious.
4. Persistently preoccupied with parts of objects.
Examples: Many children with autism are more interested in the parts of a toy. These children tend to focus on the eyes of a doll or wheels of a car, or they may become absorbed with sniffing or smelling an object. They also can become focused on moving or shiny objects, such as spinning wheels or the underside of a CD-ROM.
Thus far, this configuration of symptoms adds up to four. The other two symptoms can come from any of the three categories — meaning they could come from just one category or distributed over two.
Note on PDD-NOS: Atypical autism, or pervasive developmental disorder-not otherwise specified, is a diagnosis given to children who do not quite meet the diagnostic definition for autism but who still have impairments in the three areas indicated by classic autism, though intellectual impairment is rarer.
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