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DSM5AUTISMSPECTRUMDISORDER

GUIDELINES&CRITERIAEXEMPLARS

eneralGuidelines
Oneexampleofaspecificcriterionmaynotbesufficienttoassignthecriterionasbeingpresent.
o Istheexamplebehaviorclearlyatypical?
o Istheexamplebehaviorpresentacrossmultiplecontexts?
o Distinguishbetweenbehaviorsthatareclearlyatypicalandpresentacrossmultiplecontexts,
versusbehaviorsthatareontheborderlineofbeingatypicalorrarelyoccur/occurinonlyone
context.Forexample,whiletoewalkingmaybeanexampleofcriterionB1,itmaynotbe
sufficientbyitselftoassignthecriterionifthereisaphysicalexplanationforthebehavior(and
thusnotclearlyatypical)and/orifitoccursonlyinonecontext(e.g.atthebeachwhenbarefoot
inthesand).Bycontrast,apreoccupationwithlawnmowersthatinvolvesobsessivelydrawing
lawnmowers,seekingoutlawnmowers,andtalkingaboutlawnmowersissufficienttomeet
criterionB3evenifnootherexamplesexist.Thispreoccupationisclearlyatypicalandispresent
acrossmultiplecontexts.
Avoidusingtheexactsamebehavioralexemplartosatisfytwocriteria.
o SomebehaviorsmayappeartosatisfymultipleDSM5criteria.Itistheresponsibilityofthe
cliniciantodecidewherethebehaviorisbestrepresented.Forexample,repetitivelyputting
handsoverearsmaysatisfyB1becauseitisarepetitivemotormovement,oritmaybe
consideredunderB4becauseitrepresentsanadversereactiontosounds.
o SomebehaviorsaremultifacetedandmaysatisfymultipleDSM5criteria.Forexample,achild
whoisobsessedwithstringandinsistsonalwayscarryingstringwithhimatalltimesmaymeet
criteriaforB3duetoastrongattachmenttoanunusualobject.Ifthesamechildalsofrequently
wavesstringinfrontofhisfaceandwatchesitflopupanddown,thenB4shouldalsobe
consideredduetothevisualsensoryaspectofthisbehavior.
Behaviorsthatarenotcurrentlypresentmaybeconsidered.
o Abehaviorthatonlyoccurredinthepastmaybesufficienttoassignacriterion.
o Itisimportanttoconsiderwhetherabehaviorthatoccurredinthepastisatypicalfor
developmentalnorms(e.g.handflappingshouldnotbecountedifitonlyoccurredfrom69
monthsofage).
Everythingissubjecttochange.
o ThefinalpublicationoftheDSM5(May2013)mayprovidemoreguidanceonthenumberof
behavioralexemplarsrequired.
o Thenumberofrequiredcriteriamaychange.
o Majorchangespossible.

SM5CriteriaforASDWithExamples

A. PERSISTENTDEFICITSINSOCIALCOMMUNICATIONANDSOCIALINTERACTIONACROSSCONTEXTS,NOT
ACCOUNTEDFORBYGENERALDEVELOPMENTALDELAYS ,ANDMANIFESTBY3OF3SYMPTOMS:

A1.Deficitsinsocialemotionalreciprocity;rangingfromabnormalsocialapproachandfailureofnormalback
andforthconversationthroughreducedsharingofinterests,emotions,andaffectandresponsetototallackof
initiationofsocialinteraction.
Abnormalsocialapproach
o Unusualsocialinitiations(e.g.intrusivetouching;lickingofothers)

LauraCarpenter,PhDFebruary2013

o Useofothersastools
A1reflectsproblemswith
Failureofnormalbackandforthconversation
o Poorpragmatic/socialuseoflanguage(e.g.
socialinitiationandresponse
doesnotclarifyifnotunderstood;doesnot
providebackgroundinformation)
o Failuretorespondwhennamecalledorwhenspokendirectlyto
o Doesnotinitiateconversation
o Onesidedconversations/monologues/tangentialspeech
Reducedsharingofinterests
o Doesntshare
o Lackofshowing,bringing,orpointingoutobjectsofinteresttootherpeople
o Impairmentsinjointattention(bothinitiatingandresponding)
Reducedsharingofemotions/affect
o Lackofresponsivesocialsmile(note:thefocushereisontheresponsetoanotherpersonssmile;
otheraspectsofemotionalexpressionshouldbeconsideredunderA2).
o Failuretoshareenjoyment,excitement,orachievementswithothers
o Failuretorespondtopraise
o Doesnotshowpleasureinsocialinteractions
o Failuretooffercomforttoothers
o Indifference/aversiontophysicalcontactandaffection
Lackofinitiationofsocialinteraction
o Onlyinitiatestogethelp;limitedsocialinitiations
Poorsocialimitation
o Failuretoengageinsimplesocialgames

A2.Deficitsinnonverbalcommunicativebehaviorsusedforsocialinteraction;rangingfrompoorlyintegrated
verbalandnonverbalcommunication,throughabnormalitiesineyecontactandbodylanguage,ordeficitsin
understandinganduseofnonverbalcommunication,tototallackoffacialexpressionorgestures.

Impairmentsinsocialuseofeyecontact
Impairmentintheuseandunderstandingofbody
A2reflectsproblemswithnon
postures(e.g.facingawayfromalistener)
verbalcommunication
Impairmentintheuseandunderstandingof
gestures(e.g.pointing,waving,nodding/shaking
head)
Abnormalvolume,pitch,intonation,rate,rhythm,stress,prosodyorvolumeinspeech
Abnormalitiesinuseandunderstandingofaffect(note:responsivesocialsmileshouldbeconsideredunder
A1,whileaffectthatisinappropriateforthecontextshouldbeconsideredunderA3)
o Impairmentintheuseoffacialexpressions(maybelimitedorexaggerated)
o Lackofwarm,joyfulexpressionsdirectedatothers
o Limitedcommunicationofownaffect(inabilitytoconveyarangeofemotionsviawords,
expressions,toneofvoice,gestures)
o Inabilitytorecognizeorinterpretothersnonverbalexpressions
Lackofcoordinatedverbalandnonverbalcommunication(e.g.inabilitytocoordinateeyecontactorbody
languagewithwords)
Lackofcoordinatednonverbalcommunication(e.g.inabilitytocoordinateeyecontactwithgestures)

A3.Deficitsindevelopingandmaintainingrelationships,appropriatetodevelopmentallevel(beyondthosewith
caregivers);rangingfromdifficultiesadjustingbehaviortosuitdifferentsocialcontextsthroughdifficultiesin
sharingimaginativeplayandinmakingfriendstoanapparentabsenceofinterestinpeople
Deficitsindevelopingandmaintainingrelationships,appropriatetodevelopmentallevel
Lackoftheoryofmind;inabilitytotakeanotherpersonsperspective(CA4years)

LauraCarpenter,PhDFebruary2013

Difficultiesadjustingbehaviortosuitsocialcontexts
Doesnotnoticeanotherpersonslackofinterestinanactivity
lackofresponsetocontextualcues(e.g.socialcuesfromothersindicatingachangeinbehavioris
implicitlyrequested)
Inappropriateexpressionsofemotion(laughingorsmilingoutofcontext)(note:other
abnormalitiesintheuseandunderstandingofemotionshouldbeconsideredunderA2)
Unawareofsocialconventions/appropriatesocialbehavior;askssociallyinappropriatequestions
ormakessociallyinappropriatestatements
Doesnotnoticeanothersdistressordisinterest
Doesnotrecognizewhennotwelcomeinaplayorconversationalsetting
Limitedrecognitionofsocialemotions(doesnotnoticewhenheorsheisbeingteased;doesnot
noticehowhisorherbehaviorimpactsothersemotionally)
Difficultiesinsharingimaginativeplay(Note:solitaryimaginativeplay/roleplayingisNOTcapturedhere)
Lackofimaginativeplaywithpeers,includingsocialroleplaying(>4yearsdevelopmentalage)
Difficultiesinmakingfriends
Doesnottrytoestablishfriendships
Doesnothavepreferredfriends
Lackofcooperativeplay(over24monthsdevelopmentalage);parallelplayonly
Unawareofbeingteasedorridiculedbyotherchildren
Doesnotplayingroupsofchildren
Doesnotplaywithchildrenhis/herageordevelopmentallevel(onlyolder/younger)
Hasaninterestinfriendshipbutlacksunderstandingoftheconventionsofsocialinteraction(e.g
extremelydirectiveorrigid;overlypassive)
Doesnotrespondtothesocialapproachesofotherchildren
Absenceofinterestinothers
Lackofinterestinpeers
Withdrawn;aloof;inownworld
A3reflectsproblemswith
Doesnottrytoattracttheattentionofothers
Limitedinterestinothers;
socialawarenessandinsight,
Unawareoroblivioustochildrenoradults
aswellaswiththebroader
Limitedinteractionwithothers
Preferssolitaryactivities
conceptofsocialrelationships

B.RESTRICTED,REPETITIVEPATTERNSOFBEHAVIOR,INTERESTS,ORACTIVITIESASMANIFESTEDBYATLEAST
2OF4SYMPTOMS:
B1.Stereotypedorrepetitivespeech,motormovements,oruseofobjects;(suchassimplemotorstereotypies,
echolalia,repetitiveuseofobjects,oridiosyncraticphrases).
Stereotypedorrepetitivespeech
o Pedanticspeechorunusuallyformallanguage
(childspeakslikeanadultorlittleprofessor)
B1includesatypicalspeech,
o Echolalia(immediateordelayed);mayinclude
repetitionofwords,phrases,ormoreextensive
movements,andplay
songsordialog
o Jargonorgibberish(maturejargoningafter
developmentalageof24months)
o Useofrotelanguage
o Idiosyncraticormetaphoricallanguage(languagethathasmeaningonlytothosefamiliarwith
theindividualscommunicationstyle);neologisms
o Pronounreversal(forexample,YouforI;notjustmixingupgenderpronouns)
o Referstoselfbyownname(doesnotuseI)
o Perservativelanguage(note:forperseverationonaspecifictopic,considerB3)

LauraCarpenter,PhDFebruary2013

Repetitivevocalizationssuchasrepetitive
B3includespreoccupations
gutturalsounds,intonationalnoisemaking,
unusualsquealing,repetitivehumming
withobjectsortopics
Stereotypedorrepetitivemotormovements
o Repetitivehandmovements(e.g.,clapping,
fingerflicking,flapping,twisting)
o Stereotypedorcomplexwholebodymovements(e.g.,foottofootrocking,dipping,&swaying;
spinning)
o Abnormalitiesofposture(e.g.,toewalking;fullbodyposturing)
o Intensebodytensing
o Unusualfacialgrimacing
o Excessiveteethgrinding
o Repetitivelyputshandsoverears(note:ifresponsetosounds,considerB4)
o Perseverativeorrepetitiveaction/play/behavior(note:if2ormorecomponents,thenitisa
routineandshouldbeconsideredunderB2)
o Repetitivepicking(unlesscleartactilesensorycomponent,thenconsiderB4)
Stereotypedorrepetitiveuseofobjects
o Nonfunctionalplaywithobjects(wavingsticks;droppingitems)
o Linesuptoysorobjects
o Repetitivelyopensandclosesdoors
o Repetitivelyturnslightsonandoff
o

B2.Excessiveadherencetoroutines,ritualizedpatternsofverbalornonverbalbehavior,orexcessiveresistance
tochange;(suchasmotoricrituals,insistenceonsamerouteorfood,repetitivequestioningorextremedistress
atsmallchanges).
Adherencetoroutine
o Routines:specific,unusualmultiplestep
sequencesofbehavior
B2includesritualsand
o Insistenceonrigidlyfollowingspecific
resistancetochange
routines(note:excludebedtimeroutines
unlesscomponentsorlevelofadherenceis
atypical)
o Unusualroutines
RitualizedPatternsofVerbalandNonverbalBehavior
o Repetitivequestioningaboutaparticulartopic(distinguishfromsayingthesamewordorphrase
overandover,whichgoesunderB1)
o Verbalritualshastosayoneormorethingsinaspecificwayorrequiresotherstosaythingsor
answerquestionsinaspecificway
o Compulsions(e.g.insistenceonturninginacirclethreetimesbeforeenteringaroom)(note:
repetitiveuseofobjects,,includinglininguptoys,shouldbeconsideredunderB1).
Excessiveresistancetochange
o Difficultywithtransitions(shouldbeoutoftherangeofwhatistypicalforchildrenofthat
developmentallevel)
o Overreactiontotrivialchanges(movingitemsatthedinnertableordrivinganalternateroute)
Rigidthinking
o Inabilitytounderstandhumor
o Inabilitytounderstandnonliteralaspectsofspeechsuchasironyorimpliedmeaning
o Excessivelyrigid,inflexible,orruleboundinbehaviororthought

B3.Highlyrestricted,fixatedintereststhatareabnormalinintensityorfocus;(suchasstrongattachmenttoor
preoccupationwithunusualobjects,excessivelycircumscribedorperseverativeinterests).
Note:ConsiderB1forperservativespeech

LauraCarpenter,PhDFebruary2013

Preoccupations;obsessions
Intereststhatareabnormalinintensity
Narrowrangeofinterests
Focusedonthesamefewobjects,topicsoractivities
Preoccupationwithnumbers,letters,symbols
Beingoverlyperfectionistic
Intereststhatareabnormalinfocus
Excessivefocusonnonrelevantornonfunctionalpartsofobjects
Preoccupations(e.g.color;timetables;historicalevents;etc)
Attachmenttounusualinanimateobject(e.g.,pieceofstringorrubberband)
Havingtocarryaroundorholdspecificorunusualobjects(notcommonattachmentobjectssuchas
blankets,stuffedanimals,etc.)
Unusualfears(e.g.afraidofpeoplewearingearrings)

B4.Hyperorhyporeactivitytosensoryinputorunusualinterestinsensoryaspectsofenvironment;(suchas
apparentindifferencetopain/heat/cold,adverseresponsetospecificsoundsortextures,excessivesmellingor
touchingofobjects,fascinationwithlightsorspinningobjects).
Hightoleranceforpain
Pokingowneyes
Preoccupationwithtextureortouch(includesattraction/aversiontotexture)
o Tactiledefensiveness;doesnotliketobetouchedbycertainobjectsortextures
o Significantaversiontohavinghairortoenailscut,orteethbrushed
Unusualvisualexploration/activity
o Closevisualinspectionofobjectsorselffornoclearpurpose(forexample,holdingthingsat
unusualangels)(novisionimpairment)
o Looksatobjects,peopleoutofcornerofeye
o Unusualsquintingofeyes
B4includesatypicalsensory
o Extremeinterestorfascinationwithwatching
movementofotherthings(e.g.,thespinning
behaviors
wheelsoftoys,theopeningandclosingof
doors,electricfanorotherrapidlyrevolving
object)
Inalldomainsofsensorystimuli(sound,smell,taste,vestibular,visual),consider:
o Oddresponsestosensoryinput(e.g.becomingextremelydistressedbytheatypicalsound)
o Atypicaland/orpersistentfocusonsensoryinput
Unusualsensoryexplorationwithobjects(sound,smell,taste,vestibular)
o Lickingorsniffingobjects(note:aspartofaritual,considerB2;lickingorsniffingpeopleconsider
A1)

C.Symptomsmustbepresentinearlychildhood(butmaynotbecomefullymanifestuntilsocial
demandsexceedlimitedcapacities)

Earlyprimarycaregiverreportnolongeressential
EarlyChildhoodapproximatelyage8andyounger(flexible)

D.Symptomstogetherlimitandimpaireverydayfunctioning.

LauraCarpenter,PhDFebruary2013

SelectoneseveritylevelspecifierforSocialCommunicationandoneforRestrictedInterestsand
RepetitiveBehaviors.
Minimalsocialimpairments:Withoutsupportsinplace,deficitsinsocialcommunicationcause
noticeableimpairments.Hasdifficultyinitiatingsocialinteractionsanddemonstratesclearexamplesof
atypicalorunsuccessfulresponsestosocialoverturesofothers.Mayappeartohavedecreasedinterestin
socialinteractions.(fromDSM5severityrating)
MinimalRRBimpairments:Ritualsandrepetitivebehaviors(RRBs)causesignificantinterferencewith
functioninginoneormorecontexts.ResistsattemptsbyotherstointerruptRRBsortoberedirected
fromfixatedinterest.(fromDSM5severityrating)

SeverityLevel
forASD

Level3
Requiringvery
substantial
support

Level2
Requiring
substantial
support

Level1
Requiring
support

SocialCommunication

RestrictedInterests&RepetitiveBehaviors

Severedeficitsinverbalandnonverbal
socialcommunicationskillscause
severeimpairmentsinfunctioning;very
limitedinitiationofsocialinteractions
andminimalresponsetosocial
overturesfromothers.

Preoccupations,fixatedritualsand/orrepetitive
behaviorsmarkedlyinterferewithfunctioninginall
spheres.Markeddistresswhenritualsorroutines
areinterrupted;verydifficulttoredirectfrom
fixatedinterestorreturnstoitquickly.

Markeddeficitsinverbalandnonverbal
socialcommunicationskills;social
impairmentsapparentevenwith
supportsinplace;limitedinitiationof
socialinteractionsandreducedor
abnormalresponsetosocialovertures
fromothers.

RRBsand/orpreoccupationsorfixatedinterests
appearfrequentlyenoughtobeobvioustothe
casualobserverandinterferewithfunctioningina
varietyofcontexts.Distressorfrustrationis
apparentwhenRRBsareinterrupted;difficultto
redirectfromfixatedinterest.

Withoutsupportsinplace,deficitsin
socialcommunicationcausenoticeable
impairments.Hasdifficultyinitiating
socialinteractionsanddemonstrates
clearexamplesofatypicalor
unsuccessfulresponsestosocial
overturesofothers.Mayappearto
havedecreasedinterestinsocial
interactions.

Ritualsandrepetitivebehaviors(RRBs)cause
significantinterferencewithfunctioninginoneor
morecontexts.Resistsattemptsbyothersto
interruptRRBsortoberedirectedfromfixated
interest.

LauraCarpenter,PhDFebruary2013

Behaviors/symptomsthatarenot/maynotbecapturedinDSM5ASD
Problemswithplay/imagination
o Impairmentsinimaginative/symbolicplay
o Lackoffunctionalplayskills
o Difficultydistinguishingfantasyfromreality
Shyness/socialanxiety
Languageanddevelopmentaldelays
o Milestonedelays/developmentaldelays
o Speechdelays(expressiveorreceptive)
o Languagedisorder
Behavioraldifficulties/tempertantrums
Poorimitationskills(poorSOCIALimitationskillsAREcaptured)

Author:
LauraCarpenter,PhDBCBA
AssociateProfessorofPediatrics
MedicalUniversityofSouthCarolina
carpentl@musc.edu

Acknowledgements:
Dr.CatherineRiceandothersassociatedwiththeCDCADDM(CentersforDiseaseControlandPreventionAutism
andDevelopmentalDisabilitiesMonitoring)projectdevelopedthebroaderlistofexemplarsfromwhichthese
exemplarswereadapted.Dr.Rice,Dr.CatherineCheely,andDr.CatherineLordcollaboratedwithDr.Carpenterin
thecategorizationofbehaviorsrelativetoDSM5criteria.However,anyerrorsormisinterpretationsareDr.
Carpentersresponsibility.

LauraCarpenter,PhDFebruary2013