Editorial

Sensitivity and Specicity: DSM-IV Versus

DSM-5 Criteria for Autism Spectrum Disorder

nitially DSM was developed for psychiatrists who were interested in describing
and understanding the frequency with which mental illnesses develop in our
society. In 1980, DSM-III moved from a descriptive or conceptual approach to an
operationalized, criteria-dening approach to enable clinicians to make diagnoses
on the basis of whether a patients symptoms matched the diagnostic criteria. The
expectation of DSM-III and the subsequent DSM-III-R and DSM-IV was that
DSM-based research would identify the underlying etiologies of the disorders
included in the manuals, which would allow greater renement of the criteria and
ultimately their validation by biological measures and etiologies. Now DSM-5 is
being developed and most likely will be rolled out in 2013.
One of the major concerns of some mental health professionals and consumers is
that the proposed DSM-5 new category of autism spectrum disorder (ASD) may
exclude a substantial proportion of cognitively able individuals with pervasive
developmental disorders (PDDs) other
than autistic disorder, i.e., Aspergers
To assess the true sensitivity and
disorder or PDD not otherwise specspecicity of the DSM-5 criteria for
ied (PDD-NOS). This concern arose
ASD requires real-time evaluation of
subsequent to some published reall information gathered during
ports. In the epidemiological study of
Finnish children by Mattila et al. (1),
the evaluation.
which compared the sensitivity (i.e.,
ability to correctively identify those with the disease or disorder) of DSM-IV-TR and
the rst draft of the DSM-5 criteria for ASD, 12 (46%) of the 26 subjects with DSM-IVTR PDDs (and full-scale IQs above 50) were identied as having ASD according to the
DSM-5 criteria. In the study by McPartland et al. (2), when the rst draft of the DSM-5
criteria for ASD were applied to a data set of 657 participants in a DSM-IV eld trial
evaluating clinical diagnoses of PDDs, 60.6% of those with a clinical diagnosis of
a PDD would meet the DSM-5 criteria for ASD, indicating that 39.4% would not.
A commentary by the DSM-5 Neurodevelopmental Disorders Work Group (3)
addressed serious methodological aws in the study by McPartland and
colleagues. The work group members considered that the archived data used in
the analyses by McPartland et al. had too many inherent limitations for
assessment of the criteria proposed for DSM-5, particularly in regard to sensitivity
and specicity (i.e., ability to correctively identify those without the disease or
disorder). The work group, however, also recognized that the groups early
analyses had limitations that would be addressed through the ongoing efforts to
produce reliable, valid diagnostic criteria for DSM-5 that should be effective in
identifying the broad array of individuals with ASD.
In this issue of the Journal, Huerta et al. (4) report a study designed to
demonstrate the different rates of sensitivity and specicity based on the DSM-IV
This article is featured in this months AJP Audio
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and DSM-5 ASD criteria. The study was also designed to provide supportive data to
the DSM-5 ASD criteria. The study participants, ages 2 to 17, were obtained from
three large data sets, resulting in 4,453 subjects with DSM-IV clinical diagnoses
of (PDDs) (equivalent to ASD) and 690 subjects with non-PDD diagnoses (e.g.,
language disorder, attention decit hyperactivity disorder). Items from a parent
report measure of ASD symptoms (Autism Diagnostic InterviewRevised) and
from a clinical observation instrument (Autism Diagnostic Observation Schedule)
were matched to DSM-IV and DSM-5 criteria and then used to evaluate the
sensitivity and specicity of the DSM-IV and DSM-5 criteria when compared with
the clinical best-estimate diagnoses.
When only symptoms rated with the Autism Diagnostic Interview were used to
identify children with ASD, the sensitivity of the DSM-5 criteria (0.91) was similar to
that of the DSM-IV criteria for autistic disorder (0.91) in the combined study groups.
The DSM-IV criteria for Aspergers disorder and PDD-NOS had higher sensitivities
(0.97 and 0.98, respectively). The results suggest that the DSM-IV criteria for the
three subtypes of ASD had similar or better sensitivity than the DSM-5 criteria in
terms of identifying ASD cases. On the other hand, the results seem to indicate that
on the basis of the symptoms rated only with the Autism Diagnostic Interview,
about 9% of children with clinical diagnoses of DSM-IV PDDs would not qualify for
DSM-5 ASD.
Huerta and colleagues report that when only parent ratings from the Autism
Diagnostic Interview were used to identify children with ASD in the total study
group, the specicity of the DSM-5 criteria (0.53) was similar to the specicity of the
DSM-IV criteria for autistic disorder (0.53), but the DSM-IV criteria for Aspergers
disorder and PDD-NOS had lower specicity (0.34 and 0.24, respectively). The
overall accuracy of nonspectrum classication made by DSM-5 was slightly better
than the accuracy of the DSM-IV criteria. Nevertheless, both the DSM-IV and DSM5 criteria for ASD are moderate in correctly identifying children without ASD. The
results support the clinical observation that even with a state-of-the-art research
instrument such as the Autism Diagnostic Interview and the relatively welldeveloped DSM-IV, some borderline cases tend to be misdiagnosed as ASD
because of the high sensitivity and moderate specicity of the DSM-IV criteria for
ASD. This phenomenon may continue with the use of the DSM-5 criteria for ASD.
Hence, there is much room for improvement with respect to specicity.
Some DSM-5 ASD supporters claim that patients who have DSM-IV PDDs but fail
to qualify for DSM-5 ASD would not be left completely without mental health
services because most of them would qualify for the new DSM-5 diagnosis of social
communication disorder. It is a disappointment that Huerta and colleagues did
not investigate this aspect.
Overall, the study by Huerta et al. does provide some information to further
improve future versions of the DSM-5 criteria for ASD. Huerta et al. acknowledge
limitations of their study: the composition of two of the data sets may not be fully
representative of children typically referred for assessment of ASD; the study
instruments are largely based on the DSM-IV criteria, which may not capture the
behaviors that might t into the DSM-5 criteria; and using archival data and
symptom counts is not comparable to making clinical diagnoses. Huerta et al. also
acknowledge that the results obtained from their study may not reect the
proposed DSM-5 ASD criterias true sensitivity and specicity. I completely agree
with the thought that to assess the true sensitivity and specicity of the DSM-5
criteria for ASD requires real-time evaluation of all information gathered during the
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evaluation. However, the subjects in the study should include both children and
adults. At the present, the true sensitivity and specicity of DSM-5 criteria for ASD
are still unclear.
My major concern with the proposed DSM-5 denition and diagnostic criteria for
ASD is the decision to consolidate the subtypes of DSM-IV PDDs within the
overarching category of ASD. This change reects the thought that the symptoms
of these subtypes represent a continuum from mild to severe, rather than being
distinct disorders. In that case, I believe the term autism continuum disorder
would be more appropriate than autism spectrum disorder. On the other hand, in
supporting the proposed DSM-5 ASD criteria, one of the key members of the work
group, Dr. Francesca Happ (5), stated, To date there is not a robust, replicated
body of evidence to support the diagnostic distinction. However, the literature
review provided by Dr. Happ showed that about equal numbers of studies (about
ve studies each) reported no difference and a signicant difference between
autistic disorder and Aspergers disorder according to the different variables
examined. My own recent review of literature (6) showed that about three times
as many studies showed a signicant difference as showed no difference between
the two disorders. Thus, the opponents of DSM-5 ASD can also claim that to date
there is not a robust, replicated body of evidence to support the concept of an
autism continuum (i.e., DSM-5 ASD).
References
1. Mattila ML, Kielinen M, Linna SL, Jussila K, Ebeling H, Bloigu R, Joseph RM, Moilanen I: Autism spectrum
disorders according to DSM-IV-TR and comparison with DSM-5 draft criteria: an epidemiological study. J Am
Acad Child Adolesc Psychiatry 2011; 50:583592, e11
2. McPartland JC, Reichow B, Volkmar FR: Sensitivity and specicity of proposed DSM-5 diagnostic criteria for
autism spectrum disorder. J Am Acad Child Adolesc Psychiatry 2012; 51:368383
3. Swedo SE, Baird G, Cook EH Jr, Happ FG, Harris JC, Kaufmann WE, King BH, Lord CE, Piven J, Rogers SJ,
Spence SJ, Wetherby A, Wright HH: Commentary from the DSM-5 Workgroup on Neurodevelopmental
Disorders. J Am Acad Child Adolesc Psychiatry 2012; 51:347349
4. Huerta M, Bishop SL, Duncan A, Hus V, Lord C: Application of DSM-5 criteria for autism spectrum disorder
to three samples of children with DSM-IV diagnoses of pervasive developmental disorders. Am J Psychiatry
2012; 169:10561064
5. Happe F: Why fold Asperger syndrome into autism spectrum disorder in the DSM-5? http://sfari.org/newsand-opinion/viewpoint/2011/why-fold-asperger-syndrome-into-autism-spectrum-disorder-in-the-dsm-5
6. Tsai LY: Evolution of pervasive developmental disorder diagnosis and prediction of future direction (abstract). Chin Med J 2010; 123(suppl 2):9

LUKE Y. TSAI, M.D.

From the Department of Psychiatry, University of Michigan Medical School, Ann Arbor. Address correspondence
to Dr. Tsai (lyctsai@umich.edu). Editorial accepted for publication July 2012 (doi: 10.1176/appi.ajp.2012.
12070922).
Dr. Tsai reports no nancial relationships with commercial interests.

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