DSM-5 Definition

Everybody’s heard of autism these days, but how much do we really know about it? If we want to talk about a clinical diagnosis of Autism Spectrum Disorder (ASD,) the place to go is the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, commonly called the DSM-5. This manual gives the specific criteria that clinical or licensed psychologists use to diagnose autism.   The older edition, DSM-IV, didn’t even mention the words “autism spectrum;” it described Pervasive Developmental Disabilities (PDD) which included Autistic Disorder and Asperger’s Syndrome, among others. Now, with the newly updated 5^th edition, the PDD and Asperger’s labels are gone, replaced by the umbrella term Autism Spectrum Disorders. (Hadn’t we been calling it the autism spectrum for years? Well, the DSM finally caught up with us.)

According to the DSM-5, a person with ASD has:

A.)   DEFICITS IN SOCIAL COMMUNICATION AND INTERACTION

• This includes how the child approaches others socially. Does she lick or sniff other people? Does he use his mom’s hand as a tool to do something for him, such as placing her hand on the refrigerator door or putting her finger on the remote control? Does she get right up into people’s faces to examine them as a fascinating object, or completely avoid or ignore new people as if they weren’t even there? Most children love to see other kids their age at the park or a fast food playground, and readily approach them to join in the fun. Even shy children usually notice other children; a shy child might hide behind her parent and peek at the children, perhaps tugging on mom’s skirt and whispering, “Look, there’s kids,” even if she does not go over to play with them right away. She may wait until another child asks her to play before venturing from her mother’s side. Typically developing children don’t typically ignore or avoid other children; some, but not all, children with autism do.

• Reciprocal, social conversation is another thing to look at. Maybe a child can say a lot of words, but only uses them randomly to label and not to communicate; for example, a child might say, “Cookie,” when he sees a cookie or a picture of a cookie, but he never says, “Cookie” as a request, when he’s hungry and there is no cookie nearby. Even non-verbal infants can engage in vocal turn-taking, looking at their parents while they talk and then babbling back at them when they stop talking. Some children have super vocabularies, almost like a walking encyclopedia, but that doesn’t mean they can engage in social communication. Does your highly verbal child lecture rather than discuss, or ask one rapid-fire question after another without waiting for a response? He might have a social communication deficit, no matter how skilled he is at verbal communication.

• Some, but not all, individuals with autism seem to have a reduced sharing of interests. Many of us, when we see something interesting, whether it’s a magnificent sunset or a goofy-looking dog chasing its tail, just naturally turn to a person nearby to make sure they see it, too. We want to share the experience, whether inspiring or laughable, with another person; it just seems to make the moment more real for us. How many of us laugh as loudly when watching a comedy alone as we do in a theater full of people who are laughing at the same thing? It’s pretty much human nature to want to share our enjoyment and interests, but this is not necessarily true for everyone. Our children on the spectrum might be perfectly content to enjoy a favorite cartoon, or the perfect symmetry of sun slanting through venetian blinds, without feeling the need to try to draw our attention to what they are looking at. Maybe this is because they lack Theory of Mind: that is, they assume that we already know what they know and see what they see, so there is no need to point out the obvious. Or maybe for them the moment is perfect as it is and they don’t need another person to validate the experience. Whatever the reason, reduced sharing of enjoyment or interests is one of the characteristics of social communication deficit in autism.

• Another thing we notice is reduced sharing of emotions or affect. This has led some to imagine that autistic people don’t have feelings or empathy; often the opposite is true. People with autism may feel things very deeply and are often strongly affected by the feelings of others. They may not be able to express this in their faces or in words, and they may not know how to comfort their sister who is crying, or have any idea of what to do when someone else is emotional, but that doesn’t mean they don’t have feelings.

• Many, but not all, people with autism lack initiation of social overtures. They may not know how to ask for help when they need it. Some children just stand in the kitchen when they are hungry and wait (or scream) until an adult notices them and offers them food, rather than going to the adult to ask for a snack. Some will play if someone else asks them, but will never ask or make the first move.

• Another challenge related to social communication and interaction is poor social imitation. How do kids learn how to play games like “Ring Around the Rosie” or “Patty Cake?” By watching and imitating, that’s how. They’re just doing what they see someone else doing socially. That’s also how we learn to greet people, to join a group of children who are playing or adults who are talking. Social imitation is the way we figure out what kind of behavior is acceptable in any new situation: we look around and see what other people are doing or how they are acting, and we do it, too. When children lack social imitation, they may behave in church or a theater the same way they might behave on the playground or in a noisy pizza parlor.

• Deficits in nonverbal communicative behaviors used for social interaction is another characteristic of autism. Some people have trouble coordinating words and gestures, the way some of us have trouble walking and chewing gum at the same time. We may not realize how naturally most people “talk with their hands” until we notice someone who either remains perfectly still while talking, (“stick-like”) or whose body language or gestures appear jerky, awkward, or unrelated to what they are saying.

• A lot of people on the spectrum find it uncomfortable, or even painful, to maintain eye contact, especially while they’re trying to listen and process what the other person is saying. Some learn to accommodate by focusing on a spot between the person’s eyes or on their forehead; others just look down or even close their eyes while conversing.

• Some don’t understand tone or other nonverbal communication, such as facial expression, gestures, and attitudes. If you take every word literally without being able to read the non-word parts of the message, it’s easy to get into trouble. When a bully makes a fist and says, “You just say that one more time…” don’t say it one more time, just get away from him. When the teacher frowns and says, “Do you really think the middle of a math lesson is a good time to start talking about dinosaurs, again?” don’t answer honestly, just stop talking about dinosaurs. And if your mom says, “How many times have I told you to brush your teeth before you get into bed?” don’t tell her how many times, she does not really want to know.  All these nonverbal cues are lost on our kids on the spectrum; nine times out of ten they are not trying to be a smart aleck, and they may be completely clueless and mystified when they get in trouble. It’s just part of their nonverbal deficit.

B.)   Restricted, repetitive patterns of behavior, interests, or activities

• This may include the way a person uses objects, such as repetitively lining up toys or pens or other objects, or picking up, turning over and moving objects again and again

• It may include echolalia, repeating words verbatim; for instance, when someone asks, “What’s your name?” the echolalic child might repeat, “What’s your name?” Delayed echolalia means repeating things that were heard in the past, such as lines from a movie or TV show. At times these phrases are communicative and get the intended idea across. At other times the repeated words or phrases don’t seem to have meaning that we understand, but may help a person to self-soothe or regulate stress.

• Insisting on sameness also falls under this category; a person may want to stick with the same schedules or rigid routines every day, and may become upset if things don’t happen the way they expected.

• A lot of people on the spectrum have highly restricted, strong or intense interests. They may go on and on about their favorite topic, without noticing whether others are interested or bored.

• Some autistic people have unusual responses to sensory They may be hyper-sensitive, seeking out sensory input. These guys might stare at lights, hold noisy toys up to their ears, or touch everything and everyone within reach. They might bounce, pace or spin themselves around excessively, or sniff or taste things that are not food. Others are hypo-reactive, avoiding sensory stimulation. They might cover their eyes in the sunlight, cover their ears or be overly startled by ordinary sounds, and avoid physical activity or touch. They may be overly bothered by typical smells and may be extremely picky eaters. In fact, the same person could be both seeking and avoiding various types of sensory input, such as the child who loves to make noise by humming or tapping frequently, but hates unexpected sounds.

To be diagnosed with Autism Spectrum Disorder, a person needs to meet criteria for both A and B above. The symptoms must be present in early childhood, but may not become obvious until the person is older, when social demands may exceed their ability to “pretend to be normal.” The symptoms must cause clinically significant impairment in social, occupational, or other important areas of functioning. Also, these characteristics sometimes co-occur with other disabilities, such as intellectual disability or delay, but the symptoms are not better explained by another handicapping condition. Severity is determined by the clinician making the diagnosis.

For more information on the DSM-5, go to www.dsm5.org. For more information About Autism, check out www.interactingwithautism.com. If you want to obtain a clinical assessment or diagnosis for yourself or your child, there are a number of possible ways to go. You could ask your primary care physician for a referral, go to your local Regional Center, the MIND Institute, or contact Dr. Wendela Marsh at 887-953-PIPS (887-953-7477) for an appointment.