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Diagnostic criteria for autism spectrum disorders
DSM-IV
Diagnostic Criteria for 299.00 Autistic Disorder*
-
A total of at
least six items from (A), (B), and (C), with at least two from (A), and one
each from (B) and (C):
-
qualitive
impairment in social interaction, as manifested by at least two of the
following:
-
marked
impairment in the use of multiple nonverbal behaviours such as eye-to-eye
gaze, facial expression, body postures and gestures to regulate social
interaction
-
failure to
develop peer relationships appropriate to developmental level
-
a lack of
spontaneous seeking to share enjoyment, interests or achievements with
other people (e.g. by a lack of showing, bringing or pointing out objects
of interest)
-
lack of
social or emotional reciprocity
-
qualitive
impairments in communication as manifested by at least one of the following:
-
delay in,
or total lack of, the development of spoken language (not accompanied by
an attempt to compensate through alternative modes of communication such
as gesture or mime)
-
in
individuals with adequate speech, marked impairment in the ability to
initiate or sustain a conversation with others
-
stereotyped
and repetitive use of language or idiosyncratic language
-
lack of
varied, spontaneous make-believe play or social imitative play appropriate
to developmental level
-
Restricted
repetitive and stereotyped patterns of behaviour, interests, and activities,
as manifested by at least one of the following:
-
encompassing preoccupation with one or more stereotyped and restricted
patterns of interest that is abnormal either in intensity or focus
-
apparently
inflexible adherence to specific, non-functional routines or rituals
-
stereotyped
and repetitive motor mannerisms (e.g., hand or finger flapping or
twisting, or complex whole body movements)
-
persistent
preoccupation with parts of objects
-
Delays or
abnormal functioning in at least one of the following areas, with onset prior
to age 3 years: (1) social interaction, (2) language as used in social
communication, or (3) symbolic or imaginative play.
-
The disturbance
is not better accounted for by Rett’s Disorder or Childhood Disintegrative
Disorder.
ICD-10
Classification for F84.0 Childhood Autism**
A pervasive developmental disorder
defined by the presence of abnormal and/or impaired development that is manifest
before the age of 3 years, and by the characteristic type of abnormal
functioning in all three areas of social interaction, communication, and
restricted, repetitive behaviour. The disorder occurs in boys three to four
times more often than in girls.
Diagnostic Guidelines
Usually there is no prior period of
unequivocally normal development but, if there is, abnormalities become apparent
before the age of 3 years. There are always qualitative impairments in
reciprocal social interaction. These take the form of an inadequate appreciation
of socio-emotional cues, as shown by a lack of responses to other people's
emotions and/or a lack of modulation of behaviour according to social context;
poor use of social signals and a weak integration of social, emotional, and
communicative behaviours; and, especially, a lack of socio-emotional
reciprocity. Similarly, qualitative impairments in communications are universal.
These take the form of a lack of social usage of whatever language skills are
present; impairment in make-believe and social imitative play; poor synchrony
and lack of reciprocity in conversational interchange; poor flexibility in
language expression and a relative lack of creativity and fantasy in thought
processes; lack of emotional response to other people's verbal and nonverbal
overtures; impaired use of variations in cadence or emphasis to reflect
communicative modulation; and a similar lack of accompanying gesture to provide
emphasis or aid meaning in spoken communication.
The condition is also characterized by
restricted, repetitive, and stereotyped patterns of behaviour, interests, and
activities. These take the form of a tendency to impose rigidity and routine on
a wide range of aspects of day-to day functioning; this usually applies to novel
activities as well as to familiar habits and play patterns. In early childhood
particularly, there may be specific attachment to unusual, typically non-soft
objects. The children may insist on the performance of particular routines in
rituals of a non-functional character; there may be stereotyped preoccupations
with interests such as dates, routes or timetables; often there are motor
stereotypes; a specific interest in non-functional elements of objects (such as
their smell or feel) is common; and there may be a resistance to changes in
routine or in details of the personal environment (such as the movement of
ornaments or furniture in the family home).
In addition to these specific diagnostic
features, it is frequent for children with autism to show a range of other
non-specific problems such as fear/phobias, sleeping and eating disturbances,
temper tantrums, and aggression. Self-injury (e.g. by wrist-biting) is fairly
common, especially when there is associated severe mental retardation. Most
individuals with autism lack spontaneity, initiative, and creativity in the
organization of their leisure time and have difficulty applying
conceptualizations in decision-making in work (even when the tasks themselves
are well within their capacity). The specific manifestation of deficits
characteristic of autism change as the children grow older, but the deficits
continue into and through adult life with a broadly similar pattern of problems
in socialization, communication, and interest patterns. Developmental
abnormalities must have been present in the first 3 years for the diagnosis to
be made, but the syndrome can be diagnosed in all age groups.
All levels of IQ can occur in
association with autism, but there is significant mental retardation in some
three-quarters of cases.
Includes:
-
infantile
autism
-
infantile
psychosis
-
Kanner's
syndrome
Differential Diagnosis
Apart from the other varieties of
pervasive developmental disorder it is important to consider: specific
developmental disorder of receptive language with secondary socio-emotional
problems; reactive attachment disorder or dis-inhibited attachment disorder;
mental retardation with some associated emotional/behavioural disorder;
schizophrenia of unusually early onset; and Rett's syndrome.
Excludes:
Susan Mayes’ Checklist For Autism In Young Children***
Problems With Social Interaction
- Social isolation, withdrawal
- Limited eye contact, reciprocal interaction, social
smile, sharing, showing
- Self-absorption, oblivious to others, in own world
- Socially indiscriminate behaviour (e.g., going with
strangers or invading personal space such as touching or climbing on people),
lack of stranger and separation anxiety
- Social skills deficit
Perseveration
- Narrow or unusual range of interests and play
behaviours, obsessive preoccupations (e.g., videos, toys with wheels such as
trains, or symbols such as letters or shapes), attachment to and holding
particular objects
- Stereotyped and repetitive play (e.g., spinning,
flicking, throwing, lining up, sorting, opening and closing)
- Upset with change, difficulty with transitions,
idiosyncratic or ritualized patterns or routines, desire to maintain sameness
and order, things must be a certain way or done a particular way
- Stereotypes (e.g., repetitive or self-stimulating
movements or vocalizations such as rocking, head shaking, body tensing, toe
walking, teeth grinding or clenching, hand or finger movements, facial
grimacing, repetitive running, twirling, hand flapping or jumping when
excited, pacing, playing with saliva, picking at skin, hyperventilating)
Somatosensory Disturbance
- Love of movement, frolic play, tickling, climbing,
rocking, and swinging
- Unresponsive at times to verbal input (e.g., not
reacting when name called, hearing may be questioned even though normal)
- Hypersensitivity to some sounds (e.g., distress or
covering ears in response to loud noise, sounds made by appliances or motors,
or certain songs, commercials, or voices)
- Distress with commotion, crowds
- Fascination with specific visual stimuli such as
spinning or rhythmic movements, details, fingers, lights, shiny surfaces,
linear patterns (e.g., credits on TV, fans, Wheel of Fortune)
- Abnormal sensory inspection (e.g., mouthing, smelling,
scratching, rubbing, visually scrutinizing objects or fingers close to eyes,
placing ears against things that vibrate or hum, pressing objects against
face)
- Tactile defensiveness (e.g., dislike being touched,
touching certain things, wearing clothes, having face washed, teeth brushed,
hair combed)
- High tolerance for pain (e.g., not crying when hurt)
- Sleep disturbance (e.g., difficulty falling asleep,
awaking early or during the night)
- Feeding disorder (e.g., limited food preferences,
hypersensitivity to textures, retaining food in mouth, inconsistency in eating
over time, pica)
Atypical Developmental Pattern
- Possible developmental regression or slowing at
approximately 1-2 years of age (e.g., loss of words)
- Visual and motor skills higher than expressive and
receptive language, especially for children with delayed development
- Expressive language disorder: (1) no speech or absence
of communicative speech with nonverbal communication at a higher level than
verbal (e.g., pulling others by the hand and leading to what wants) or (2)
limited reciprocal conversational speech (versus communication in stress- and
need-related situations, self-directed verbalizations, or speaking on topics
of interest to self)
- Atypical vocalizations such as unusual voice quality or
modulation, screeching, odd noises, repetitive vocalizations, echolalia,
idiosyncratic jargon or speech, preservative speech, sporadic speech (e.g.,
uttering a word or phrase once and rarely or never saying it again), rote
phrases out of context (from the past or videos), nonsensical speech, pronoun
substitutions
- Splinter skills: specific abilities significantly above
the child's mental age that often involve (1) rote memory (e.g.,
identification of numbers, letters, shapes, logos, and colours; singing or
humming tunes; memorizing car routes; counting; saying the alphabet; reading;
spelling; reciting segments from videos or books), (2) visual, manipulative,
or mechanical skills (e.g., completing puzzles, matching shapes, using a
computer or VCR), or (3) gross motor skills
Mood Disturbance
- Overactivity, irritability, agitation, tantrums,
aggression, self-injurious behaviour (distressed by input or occurrences most
children can tolerate such as intrusions, activity interruptions, proximity,
confinement, performance demands)
- Emotional lability with mood changes sometimes
internally triggered (e.g., laughing or becoming upset for no apparent reason)
- Flat affect, unresponsive in some situations
- Unusual fears (e.g., elevators, steps, toilets)
Problems With Attention and Safety
- Selective attention, situational over-activity (e.g.,
hyper-focused on activities, objects, or topics of interest to self and
inattentive at other times)
DSM-IV Diagnostic Criteria for 299.80 Asperger's
Disorder*
- Qualitative impairment in social interaction,
as manifested by at least two of the following:
- marked impairment in the use of multiple nonverbal
behaviours such as eye-to-eye gaze, facial expression, body postures, and
gestures to regulate social interaction
- failure to develop peer relationships appropriate to
developmental level
- a lack of spontaneous seeking to share enjoyment,
interests, or achievements with other people (e.g., by a lack of showing,
bringing, or pointing out objects of interest)
- lack of social or emotional reciprocity
- Restricted repetitive and stereotyped patterns
of behaviour, interests, and activities, as manifested by at least one of the
following:
- encompassing preoccupation with one or more
stereotyped and restricted patterns of interest that is abnormal either in
intensity or focus
- apparently inflexible adherence to specific,
non-functional routines or rituals
- stereotyped and repetitive motor mannerisms (e.g.,
hand or finger flapping or twisting, or complex whole body movements)
- persistent preoccupation with parts of objects
- The disturbance causes clinically significant
impairments in social, occupational, or other important areas of functioning
- There is no clinically significant general
delay in language (e.g., single words used by age 2 years, communicative
phrases used by age 3 years)
- There is no clinically significant delay in
cognitive development or in the development of age-appropriate self-help
skills, adaptive behaviour (other than social interaction), and curiosity
about the environment in childhood
- Criteria are not met for another specific
Pervasive Developmental Disorder or Schizophrenia
ICD-10 Classification for F84.5 Asperger’s Syndrome**
A disorder of uncertain nosological
validity, characterized by the same kind of qualitative abnormalities of
reciprocal social interaction that typify autism, together with a restricted,
stereotyped, repetitive repertoire of interests and activities. The disorder
differs from autism primarily in that there is no general delay or retardation
in language or in cognitive development. Most individuals are of normal general
intelligence but it is common for them to be markedly clumsy; the condition
occurs predominately in boys (in a ratio of about eight boys to one girl). It
seems highly likely that at least some cases represent mild varieties of autism,
but it is uncertain whether or not that is so for all. There is a strong
tendency for the abnormalities to persist into adolescence and adult life and it
seems that they represent individual characteristics that are not greatly
affected by environmental influences. Psychotic episodes occasionally occur in
early adult life.
Diagnostic Guidelines
Diagnosis is based on the combination of
a lack of any clinically significant general delay in language or cognitive
development plus, as with autism, the presence of qualitative deficiencies in
reciprocal social interaction and restricted, repetitive, stereotyped patterns
of behaviour, interests, and activities. There may or may not be problems in
communication similar to those associated with autism, but significant language
retardation would rule out the diagnosis.
Includes:
Excludes:
-
anaclastic
personality disorder
-
attachment
disorders of childhood
-
obsessive-compulsive disorder
-
schizo-typical disorder
-
simple
schizophrenia
Christopher
Gillberg’s Criteria For Asperger Syndrome****
Severe impairment in reciprocal social
interaction (at least two of the following):
-
inability to interact with peers
-
lack of desire to interact with peers
-
lack of appreciation of social cues
-
socially and emotionally inappropriate
behaviour
All-absorbing narrow interest (at least
one of the following):
-
exclusion of other activities
-
repetitive adherence
-
more rote than meaning
Imposition of routines and interests (at
least one of the following):
-
on self, in aspects of life
-
on others
Speech and language problems (at least
three of the following):
-
delayed development
-
superficially perfect expressive
language
-
formal, pedantic language
-
odd prosody, peculiar voice
characteristics
-
impairment of comprehension including
misinterpretations of literal/implied meanings
Non-verbal communication problems (at
least one of the following):
-
limited use of gestures
-
clumsy/gauche body language
-
limited facial expression
-
inappropriate expression
-
peculiar, stiff gaze
Motor clumsiness: poor performance on
neuro-developmental examination
All six criteria must be met for confirmation of
diagnosis
Pervasive Developmental Disorder Not Otherwise Specified
DSM-IV Diagnostic Criteria for 299.80 Pervasive
Developmental Disorder Not Otherwise Specified (Including Atypical Autism)*
This category should be used when there
is a severe and pervasive impairment in the development of reciprocal social
interaction or verbal and nonverbal communication skills, or when stereotyped
behaviour, interests, and activities are present, but the criteria are not met
for a specific Pervasive Developmental Disorder, Schizophrenia, Schizo typal
Personality Disorder, or Avoidant Personality Disorder. For example, this
category includes atypical autism --- presentations that do not meet the
criteria for Autistic Disorder because of late age of onset, atypical
symptomatology, or subthreshold symptomatology, or all of these.
ICD-10 Classification for F84.1 Atypical Autism**
A pervasive developmental disorder that
differs from autism in terms either of age of onset or of failure to fulfil all
three sets of diagnostic criteria. Thus, abnormal and/or impaired development
becomes manifest for the first time only after age 3 years; and/or there are
insufficient demonstrable abnormalities in one or two of the three areas of
psychopathology required for the diagnosis of autism (namely, reciprocal social
interactions, communication, and restrictive, stereotyped, repetitive behaviour)
in spite of characteristic abnormalities in the other area(s). Atypical autism
arises most often in profoundly retarded individuals whose very low level of
functioning provides little scope for exhibition of the specific deviant
behaviours required for the diagnosis of autism; it also occurs in individuals
with a severe specific developmental disorder of receptive language. Atypical
autism thus constitutes a meaningfully separate condition from autism.
Includes:
ICD-10
Classification for F84.9 Pervasive Developmental Disorders, Unspecified**
This is a residual diagnostic category
that should be used for disorders which fit the general description for
pervasive developmental disorders but which a lack of adequate information, or
contradictory findings, means that the criteria for any of the other
F84 codes
cannot be met.
-
*American Psychiatric Association.
(1994). Diagnostic and statistical manual of mental disorders (4th
ed.). Washington, DC: Author.
-
**World Health Organisation. (1992).
International classification of diseases and health related problems (10th
ed.). Geneva: Author.
-
***Mayes, S. D., & Calhoun, S. L.
(2001). Non-significance of early speech delay in children with autism and
normal intelligence and implications for DSM-IV Asperger’s disorder.
Autism, 5(1), 81-94; Mayes, S. D., Calhoun, S. L., & Crites, D. L. (2001).
Does DSM-IV Asperger’s disorder exist? Journal of Abnormal Child
Psychology, 29(3), 163-171.
-
****Gillberg, I. C., & Gillberg, C.
(1989). Asperger syndrome – some epidemiological considerations: A research
note. Journal of Child Psychology & Psychiatry, 30, 631-638; Gillberg,
C. (1991). Clinical and neurobiological aspects of Asperger syndrome in six
family studies. In U. Frith (Ed.), Autism and Asperger syndrome (pp.
122- 146). Cambridge, UK: Cambridge University Press.
Larry Cashion for A4
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