DSM-IV to DSM-5 changes in diagnostic criteria for Autism Spectrum Disorder

## **Brief History**

Before the *Diagnostic and Statistical Manual of Mental Disorders* (DSM) was created, the American Psychological Association (APA) published a statistical classification of institutionalized mental patients in 1844. The APA created this classification in order to improve communication about the types of patients that were being treated in the hospitals. After World War II, the DSM transformed through four major editions that included classifications that would be approved by all members of its organization and integrate the diagnostic terms of its psychiatrists. The APA created the DSM in 1952.  The APA created the DSM in order to have a common language for mental health professionals in the United States to use when diagnosing individuals with mental disorders. This diagnostic classification system allowed physicians, psychiatrists, and other mental health professionals to communicate using a common language and included a wide range of essential characteristics of mental disorders.

There have been five subsequent editions of the DSM since the initial publication of this manual. The DSM-I had 128 diagnoses and when DSM-II was published in 1968, it included 193 diagnoses. In 1980 the DSM-III was published and in 1987 the DSM-III-R was published. The DSM-IV included 383 diagnoses and was published in 1994. The current edition of the DSM is the fifth edition which was published in 2013 and includes 541 diagnoses. The classification of psychopathology is fundamental to behavioral health disciplines and to the science and practice of clinical psychology. The DSM is used by researchers and clinicians to classify and diagnose mental disorders. The criteria are explicit and concise in order to allow an objective assessment of symptom presentation within a variety of clinical settings such as partial hospitals, clinical, private practice, primary care, inpatient, and outpatient.

## Changes in Diagnostic Criteria From DSM-IV to DSM-5 for ASD

The release of the DSM-5 in May 2013 included major changes to the diagnosis of autism from earlier versions. Some of the major changes include the elimination of Pervasive Developmental Disorder (PDD) and its five subtypes originally in the DSM-IV.  The DSM-IV subtypes are Autistic Disorder, Asperger's Disorder, Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS), Rett syndrome and Childhood Disintegrative Disorder (CDD). and formally created the diagnosis of autism spectrum disorder (ASD). This change was made to acknowledge the understanding that these categories were describing symptoms under the same umbrella rather than different disorders altogether. Another major change from the DSM-IV PDD three-domain criteria composed of social reciprocity, communication, and restricted and repetitive behaviors (RRB) to two DSM-5 ASD d0main criteria consisting of social communication/interaction and RRB. The DSM-5 added sensory symptoms in the RRB component of the diagnostic criteria which the DSM-IV did not include. Lastly, the DSM-5 changed the specification of the age of onset from "age three" to "early childhood".

The revision of criteria for ASD was led by 14 members of an interdisciplinary Neuro-developmental Disorders Workgroup. The group consisted of a developmental pediatrician, psychologists, child psychiatrists, neurologists, and a speech-language pathologist. Since the diagnosis of autism is becoming increasingly made during early childhood, there is an emphasis placed on pediatrics and primary care settings for screening autism.

The DSM has been the foundation of progress in reliability, it has been well acknowledged by the broad scientific community working on mental disorders and the APA that previous science wasn't developed enough to facilitate a fully validated diagnosis. Past science was not mature enough to provide strong, consistent, and objective scientific confirmation of individual DSM disorders. Since the science of mental disorders continues to evolve, there have been updates to the DSM throughout the past 70 years.

## Autism Spectrum Disorder Classification

Autism is derived from the Greek word "autós", which refers to "self, same, spontaneous; directed from within". This term was first coined in 1908 by Eugen Bleuler, a Swiss psychiatrist. It was originally used to describe withdrawal from reality in patients with schizophrenia but was later redefined in 1943 by Leo Kanner. Leo Kanner used the term to explain the symptoms of linguistic disorders and symptoms of social isolation in children without schizophrenia or other known psychiatric disorders. These children had difficulty interacting with others, difficulty communicating, displayed repetitive behaviors, and loss of interest in social activities. Leo Kanner used the term "early infantile autism" to represent children who lacked interest in other people. Hans Asperger identified children with social isolation and lacked linguistic abnormalities similar to children with autism in 1944. Hans Asperger independently described a different group of children than Leo Kanner that had similar behaviors, but with higher intellectual abilities and milder severity. This later led to the diagnosis of a higher functioning form of autism, known as "Asperger's Syndrome".

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder. The onset of neurodevelopmental disorders is during the developmental period and they are a group of conditions. The needs and abilities of individuals with ASD vary and change over time. These disorders manifest early in development and are characterized by developmental deficits that impair social, academic, personal, or occupational functioning. ASD is characterized by persistent deficits in social interaction and social communication across multiple contexts, including deficits in nonverbal communicative behaviors used for social interaction, social reciprocity, understanding relationships, and skills in developing relationships. The diagnosis of ASD also requires the presence of restricted, repetitive patterns of behavior, interests, or activities in addition to social communication deficits. In order to meet the diagnostic criteria for ASD, the individual must have persistent deficits in each of the three areas of social communication and interaction, in addition to at least two of four types of restricted, repetitive behaviors.

The DSM-5 criteria for ASD introduced a variety of specifiers. These additions give additional information about the current presentation of the individual who meets the criteria for ASD. The severity specifiers for ASD can be used to describe the current symptomatology, with the understanding that the severity might vary depending on context and fluctuate over time. The severity specifier describes the required level of support and impact on an individual's level of function separately for each domain of symptoms. There are three severity levels for ASD. A severity level 1 suggests that the individual with ASD "requires support". Level 2 states that the individual "requires substantial support".  Lastly, level 3 states that an individual with ASD "requires very substantial support".  The severity rating for restricted, repetitive behaviors and severity of social communication difficulties should be rated separately. Some individuals diagnosed with ASD can live independently, however, others have more severe presentations and require life-long support and care. Another specifier describes whether a known etiological factor such as a genetic syndrome, environmental exposure, or medical condition exists. A third specifier is whether the individual has an intellectual impairment. The fourth specifier suggests whether the individual has a language impairment. Lastly, whether catatonia is present is indicated, All of these specifiers are meant to help replace the previous multiaxial system.

## Prevalence

In 1996, the Center for Disease Control and Prevention (CDC) started monitoring the prevalence of ASD. The CDC first began conducting studies on children in the metropolitan Atlanta, Georgia area. The Children's Health Act of 2000 allowed the CDC to create the Autism and Developmental Disabilities Monitoring (ADDM) Network. Beginning in 2000, the CDC has continued to support the biennial surveillance of ASD prevalence within multiple communities.

The reported frequencies for ASD suggest approximately 1% of the population across the United States (U.S.) and non-U.S. countries are diagnosed with ASD. In 2018, the ADDM Network conducted active surveillance of ASD. Approximately one in 44 children aged 8 years were classified as having ASD. The prevalence estimates across child and adult samples are similar. It is unclear whether the higher rates of autism might be caused by the expansion of the diagnostic criteria of the DSM-IV to include sub-threshold cases, differences in study methodology, increased awareness, or a true increase in the occurrence of ASD. The higher prevalence of ASD since 1985 could be a combination of better case ascertainment, diagnostic substitution, greater public awareness, and corresponding diagnostic criteria and changes in the diagnostic constructs.

Diagnostic substitution can play a significant role in the rising prevalence of ASD. Diagnostic substitution occurs when an individual is diagnosed with one condition at one time and another condition at a further point in time because of individual condition, net of changes to diagnostic standards, practices, and procedures. It's likely for diagnostic substitution to occur because autism is already difficult to diagnose given that the symptoms are difficult to assess and there are no known biological markers.

## Diagnostic Issues

There are different norms for nonverbal communication, relationships, and social interactions across cultures. However, individuals with ASD are impaired against the norms depending on their cultural context. The age at recognition and diagnosis may be impacted by socioeconomic factors and culture. For example, African American children in the United States might get a later or under diagnosis of Autism Spectrum Disorder. The surveillance program in 2018 showed that ASD prevalence was similar across racial and ethnic groups. However, there was a higher prevalence of ASD among American Indian/Alaska Native children in comparison to non-Hispanic White (White) children. For African American children with ASD, cultural factors such as ASD symptom interpretations and health care access can impact delayed diagnosis and treatment. The clinical presentation of ASD does not differ by race, however, the prevalence differs across racial groups. African American children are more often misdiagnosed, diagnosed later, and with more severe ASD than Caucasian children.

The diagnosis of ASD is four times more often in males than it is in females. In 2018, the ADDM found that ASD was 4.2 times as prevalent among boys in comparison to girls. Females in clinical samples are more likely to show intellectual disability characteristics. In addition, girls without accompanying language delays or intellectual impairments might go unrecognized because of the slight manifestation of communication and social difficulties in comparison to boys.

## Debates Over the Changes in Diagnostic Criteria

Early diagnosis and intervention for autism are fundamental in improving communication, learning, and other skills. The prevalence rates of ASD have been rising drastically over the past three decades, but researchers don't know whether the rise is due to a "true" increase in cases, better detection of ASD, or both.

The change in diagnostic criteria for ASD from the DSM-IV to the DSM-5 had led to debates within the lay community and scientific community. There have been debates over whether these changes in diagnostic criteria will affect the eligibility of individuals for clinical and other services, and alter the way individuals are diagnosed with ASD. These debates create controversy among professionals in the field, as well as confusion and anxiety for families, patients, providers, and policymakers. There are concerns that the DSM-5 ASD and the removal of Autism, Asperger, and PDD diagnoses will affect the prevalence in addition to the eligibility of services. There are concerns that people originally diagnosed under the DSM-IV diagnoses will lose their diagnosis under the new criteria. If individuals lose their diagnosis because of the new criteria, this could subsequently cause a loss of services.

Changes in the definition of ASD could greatly reduce the high rate at which autism is diagnosed.  For individuals that no longer meet the criteria for ASD, it might be harder to receive educational, social services, and health services. The changes from the DSM-IV to DSM-5 might end up excluding people with an ASD diagnosis who were at the higher functioning end. If children on the higher functioning end or originally met the criteria for Asperger's Syndrome according to the DSM-IV, they aren't going to get the services and supports they need because they won't meet the criteria for ASD according to the DSM-5. These children might end up having more difficulties especially in the school setting with these changes in the DSM criteria for ASD.

## DSM-5-TR (2022)

A new version of the Diagnostic and Statistical Manual of Mental Disorders was released on March 18, 2022.
The new version is known as the DSM-5-TR. The DSM-5-TR is a text revision of the dSM-5 and includes fully revised text and new references, clarifications to diagnostic criteria, and updates to ICD-10-CM codes since DSM-5 was published. This version includes a new disorder, prolonged Grief disorder, as well as codes for suicidal behavior.

## References

1. ↑ American Psychiatric Association. (2013). *Diagnostic and statistical manual of mental disorders* (5th ed.). Washington, DC. https://doi.org/10.1176/appi.books.9780890425596
2. ↑ Blashfield, R.K., Keeley, J.W., Flanagan, E.H., & Miles, S.R. (2014). The cycle of classification: DSM-I through DSM-5. *The Annual Review of Clinical Psychology, 10,* 25-51. doi: 10.1146/annurev-clinpsy-032813-153639
3. ↑ Wright, J. (2013). DSM-5 redefines autism. *Spectrum News Opinion.* Retrieved December 4, 2021, from https://www.spectrumnews.org/opinion/dsm-5-redefines-autism/
4. ↑ American Psychiatric Association. (2021). *DSM History.* https://www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm
5. ↑ Kim, Y.S., Fombonne, E., Koh, Y.J., Kim, S.J., Cheon, K.A., & Leventhal, B. (2014). A comparison of DSM-IV PDD and DSM-5 ASD prevalence in an epidemiologic sample. *Journal of the American Academy of Child & Adolescent Psychiatry, 53*(5), 500-508. doi:10.1016/j.jaac.2013.12.021
6. ↑ King, B. (2014). Sunsetting DSM-IV's Pervasive Developmental Disorder. *Journal of the American Academy of Child & Adolescent Psychiatry, 53*(5), 494-496.
7. ↑ Harker, C.M., & Stone, W.L. (2014). Comparison of the diagnostic criteria for Autism Spectrum Disorder across DSM-5, DSM-IV-TR, and the Individuals with Disabilities Education Act (IDEA) definition of Autism. *University of Washington READi Lab (Research on Early Autism Detection and Intervention),* 1-6. https://iris.peabody.vanderbilt.edu/wp-content/uploads/pdf\_info\_briefs/ASD\_Comparison\_information\_brief.pdf
8. ↑ Grant, R. & Nozyce, M. (2013). Proposed changes to the American Psychiatric Association diagnostic criteria for Autism Spectrum Disorder: Implications for young children and their families. *Maternal and Child Health Journal, 17,* 586-592. DOI 10.1007/s10995-013-1250-9
9. ↑ Sharma, S.R., Gonda, X., & Tarazi, F.I. (2018). Autism Spectrum Disorder: Classification, diagnosis and therapy. *Pharmacology & Therapeutics, 190,* 91-104. doi: 10.1016/j.pharmthera.2018.05.007
10. ↑ Uddin, L. (2011). The self in autism: An emerging view from neuroimaging. *Neurocase, 17*(3), 201-208. doi:10.1080/13554794.2010.509320
11. ↑ Faras, H., Ateeqi, N.A., & Tidmarsh, L. (2010). Autism spectrum disorders. *Annals of Saudi Medicine, 30*(4), 295-300. doi: 10.4103/0256-4947.65261
12. ↑ Tsai, L.Y., & Ghaziuddin, M. (2014). DSM-5 ASD moves forward into the past. *Journal of Autism and Developmental Disorders, 44,* 321-330. doi: 10.1007/s10803-013-1870-3
13. ↑ Happé, F. Autism as a neurodevelopmental disorder of mind-reading. *Journal of the British Academy, 3,* 197-209. doi: 10.5871/jba/003.197
14. ↑ World Health Organization. *Autism spectrum disorders*. World Health Organization. Retrieved December 5, 2021, from https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders.
15. ↑ WebMD. *What is autism?* WebMD. Retrieved December 5, 2021, from https://www.webmd.com/brain/autism/understanding-autism-basics.
16. ↑ U.S. Department of Health and Human Services. *Autism spectrum disorder (ASD)*. National Institute of Mental Health. Retrieved December 5, 2021, from https://www.nimh.nih.gov/health/statistics/autism-spectrum-disorder-asd.
17. ↑ Centers for Disease Control and Prevention. (2020, June 29). *Diagnostic Criteria for 299.00 Autism Spectrum Disorder.* CDC. https://www.cdc.gov/ncbddd/autism/hcp-dsm.html
18. ↑ Volkmar, F.R., & McPartland, J.C. (2014). From Kanner to DSM-5: Autism as an evolving diagnostic concept. *Annual Review of Clinical Psychology, 10,* 193-212. doi: 10.1146/annurev-clinpsy-032813-153710
19. ↑ Jump up to:19.0 19.1 19.2 19.3 19.4 19.5 19.6 19.7 19.8 Christensen, D.L., Braun, K., Baio, J., Bilder, D., Charles, J., Constantino, J. N., Daniels, J., Durkin, M.S., Fitzgerald, R.T., Kurzius-Spencer, M., Lee, L.C., Pettygrove, S., Robinson, C., Schulz, E., Wells, C., Wingate, M.S., Zahorodny, W., & Yeargin-Allsopp, M. (2018). Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2012. *Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C. : 2002)*, *65*(13), 1–23. https://doi.org/10.15585/mmwr.ss6513a1
20. ↑ Gonzalez, O. (2021, December 2). *CDC: Data suggests 1 in 44 children diagnosed with autism*. Axios. Retrieved December 5, 2021, from https://www.axios.com/cdc-children-autism-diagnosis-2638f0c3-8d83-4e55-b0d4-a3f6099f33e7.html.
21. ↑ Jump up to:21.0 21.1 21.2 21.3 *U.S. autism rates up 10 percent in new CDC report*. Johns Hopkins Bloomberg School of Public Health. Retrieved December 5, 2021, from https://publichealth.jhu.edu/2020/us-autism-rates-up-10-percent-in-new-cdc-report.
22. ↑ Jump up to:22.0 22.1 22.2 King, M. & Bearman, P. (2009). Diagnostic change and the increased prevalence of autism. *International Journal of Epidemiology, 38,* 1224-1234. doi:10.1093/ije/dyp261
23. ↑ Burkett, K., Morris, E., Manning-Courtney, P., Anthony, J., & Shambley-Ebron, D. (2015). African American families on autism diagnosis and treatment: The influence of culture. *Journal of Autism and Developmental Disorders, 45,* 3244-3254. doi:10.1007/s10803-015-2482-x
24. ↑ Carey, B. (2012, January 19). New definition of autism will exclude many, study suggests. *The New York Times.* https://www.nytimes.com/2012/01/20/health/research/new-autism-definition-would-exclude-many-study-suggests.html

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1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 American Psychiatric Association. (2013). *Diagnostic and statistical manual of mental disorders* (5th ed.). Washington, DC. https://doi.org/10.1176/appi.books.9780890425596
2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Blashfield, R.K., Keeley, J.W., Flanagan, E.H., & Miles, S.R. (2014). The cycle of classification: DSM-I through DSM-5. *The Annual Review of Clinical Psychology, 10,* 25-51. doi: 10.1146/annurev-clinpsy-032813-153639
3. ↑ 3.0 3.1 3.2 3.3 3.4 Wright, J. (2013). DSM-5 redefines autism. *Spectrum News Opinion.* Retrieved December 4, 2021, from https://www.spectrumnews.org/opinion/dsm-5-redefines-autism/
4. ↑ 4.0 4.1 American Psychiatric Association. (2021). *DSM History.* https://www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm
5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 Kim, Y.S., Fombonne, E., Koh, Y.J., Kim, S.J., Cheon, K.A., & Leventhal, B. (2014). A comparison of DSM-IV PDD and DSM-5 ASD prevalence in an epidemiologic sample. *Journal of the American Academy of Child & Adolescent Psychiatry, 53*(5), 500-508. doi:10.1016/j.jaac.2013.12.021
6. ↑ King, B. (2014). Sunsetting DSM-IV's Pervasive Developmental Disorder. *Journal of the American Academy of Child & Adolescent Psychiatry, 53*(5), 494-496.
7. ↑ 7.0 7.1 7.2 Harker, C.M., & Stone, W.L. (2014). Comparison of the diagnostic criteria for Autism Spectrum Disorder across DSM-5, DSM-IV-TR, and the Individuals with Disabilities Education Act (IDEA) definition of Autism. *University of Washington READi Lab (Research on Early Autism Detection and Intervention),* 1-6. https://iris.peabody.vanderbilt.edu/wp-content/uploads/pdf\_info\_briefs/ASD\_Comparison\_information\_brief.pdf
8. ↑ 8.0 8.1 8.2 Grant, R. & Nozyce, M. (2013). Proposed changes to the American Psychiatric Association diagnostic criteria for Autism Spectrum Disorder: Implications for young children and their families. *Maternal and Child Health Journal, 17,* 586-592. DOI 10.1007/s10995-013-1250-9
9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 Sharma, S.R., Gonda, X., & Tarazi, F.I. (2018). Autism Spectrum Disorder: Classification, diagnosis and therapy. *Pharmacology & Therapeutics, 190,* 91-104. doi: 10.1016/j.pharmthera.2018.05.007
10. ↑ Uddin, L. (2011). The self in autism: An emerging view from neuroimaging. *Neurocase, 17*(3), 201-208. doi:10.1080/13554794.2010.509320
11. ↑ 11.0 11.1 11.2 11.3 Faras, H., Ateeqi, N.A., & Tidmarsh, L. (2010). Autism spectrum disorders. *Annals of Saudi Medicine, 30*(4), 295-300. doi: 10.4103/0256-4947.65261
12. ↑ 12.0 12.1 Tsai, L.Y., & Ghaziuddin, M. (2014). DSM-5 ASD moves forward into the past. *Journal of Autism and Developmental Disorders, 44,* 321-330. doi: 10.1007/s10803-013-1870-3
13. ↑ Happé, F. Autism as a neurodevelopmental disorder of mind-reading. *Journal of the British Academy, 3,* 197-209. doi: 10.5871/jba/003.197
14. ↑ 14.0 14.1 World Health Organization. *Autism spectrum disorders*. World Health Organization. Retrieved December 5, 2021, from https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders.
15. ↑ 15.0 15.1 WebMD. *What is autism?* WebMD. Retrieved December 5, 2021, from https://www.webmd.com/brain/autism/understanding-autism-basics.
16. ↑ U.S. Department of Health and Human Services. *Autism spectrum disorder (ASD)*. National Institute of Mental Health. Retrieved December 5, 2021, from https://www.nimh.nih.gov/health/statistics/autism-spectrum-disorder-asd.
17. ↑ Centers for Disease Control and Prevention. (2020, June 29). *Diagnostic Criteria for 299.00 Autism Spectrum Disorder.* CDC. https://www.cdc.gov/ncbddd/autism/hcp-dsm.html
18. ↑ 18.0 18.1 18.2 18.3 18.4 18.5 18.6 18.7 Volkmar, F.R., & McPartland, J.C. (2014). From Kanner to DSM-5: Autism as an evolving diagnostic concept. *Annual Review of Clinical Psychology, 10,* 193-212. doi: 10.1146/annurev-clinpsy-032813-153710
19. ↑ 19.0 19.1 19.2 19.3 19.4 19.5 19.6 19.7 19.8 Christensen, D.L., Braun, K., Baio, J., Bilder, D., Charles, J., Constantino, J. N., Daniels, J., Durkin, M.S., Fitzgerald, R.T., Kurzius-Spencer, M., Lee, L.C., Pettygrove, S., Robinson, C., Schulz, E., Wells, C., Wingate, M.S., Zahorodny, W., & Yeargin-Allsopp, M. (2018). Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2012. *Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C. : 2002)*, *65*(13), 1–23. https://doi.org/10.15585/mmwr.ss6513a1
20. ↑ Gonzalez, O. (2021, December 2). *CDC: Data suggests 1 in 44 children diagnosed with autism*. Axios. Retrieved December 5, 2021, from https://www.axios.com/cdc-children-autism-diagnosis-2638f0c3-8d83-4e55-b0d4-a3f6099f33e7.html.
21. ↑ 21.0 21.1 21.2 21.3 *U.S. autism rates up 10 percent in new CDC report*. Johns Hopkins Bloomberg School of Public Health. Retrieved December 5, 2021, from https://publichealth.jhu.edu/2020/us-autism-rates-up-10-percent-in-new-cdc-report.
22. ↑ 22.0 22.1 22.2 King, M. & Bearman, P. (2009). Diagnostic change and the increased prevalence of autism. *International Journal of Epidemiology, 38,* 1224-1234. doi:10.1093/ije/dyp261
23. ↑ 23.0 23.1 23.2 Burkett, K., Morris, E., Manning-Courtney, P., Anthony, J., & Shambley-Ebron, D. (2015). African American families on autism diagnosis and treatment: The influence of culture. *Journal of Autism and Developmental Disorders, 45,* 3244-3254. doi:10.1007/s10803-015-2482-x
24. ↑ 24.0 24.1 24.2 24.3 24.4 Carey, B. (2012, January 19). New definition of autism will exclude many, study suggests. *The New York Times.* https://www.nytimes.com/2012/01/20/health/research/new-autism-definition-would-exclude-many-study-suggests.html