Asian Journal of Psychiatry 11 (2014) 93–97

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Autism in DSM-5 under the microscope: Implications to patients,

families, clinicians, and researchers
Lawrence K. Fung *, Antonio Y. Hardan
Division of Child & Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, United States

A R T I C L E I N F O A B S T R A C T

Article history: The changes in the diagnostic classification of the pervasive developmental disorders from the 4th
Received 24 May 2014 edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) to DSM-5 are expected to
Received in revised form 23 August 2014 affect patients with autism, their families, as well as clinicians and researchers in the field of autism. This
Accepted 25 August 2014
article reviews the new DSM-5 diagnostic criteria for Autism Spectrum Disorder (ASD) and Social
Communication Disorder (SCD), and discusses potential consequences in the perspectives of major
Keywords: stakeholders.
Autism Spectrum Disorder
ß 2014 Elsevier B.V. All rights reserved.
Social Communication Disorder
Asperger’s Disorder
Pervasive Developmental Disorder
DSM-5

1. Introduction 1.1. Historical developments of DSM and diagnostic criteria of autism

According to the most recent report by the Centers for Disease Some of the first attempts to formally classify psychopathology
Control and Prevention, the prevalence of Autism Spectrum in the United States were undertaken during the early twentieth
Disorder (ASD) among children aged 8 years was estimated to be century. In 1918, the American Medico-Psychological Association
14.7 per 1000 (one in 68) in the United States in 2010 (CDC, 2014). (now the American Psychiatric Association) first attempted the
Approximately one in 42 boys and one in 189 girls living in the 11 creation of a formal, standardized nomenclature of psychopatho-
participating sites were identified as having ASD (CDC, 2014). logical conditions. Leo Kanner and Hans Asperger first described
These newest data continue to indicate that this public health the symptoms of children with autism in the 1940’s. In 1952, the
issue is worsening. The changes in ASD classification from the 4th first edition of DSM was published. Influenced by Freud’s powerful
edition of the Diagnostic and Statistical Manual for Mental developments of psychoanalysis, DSM-I assumed that the etiology
Disorders (DSM-IV) to DSM-5 are expected to affect the of mental illness was driven by the subconscious, and was
prevalence of the disorders and result in significant consequences designed to guide psychodynamic formulations. DSM-I marked the
for patients, clinicians, and researchers. Therefore, the objectives first mention of autism under Schizophrenic Reaction, Childhood
of this article are to introduce the new diagnostic criteria for ASD Type’’. In 1968, when DSM-II was released, autism was listed under
and Social (Pragmatic) Communication Disorder (SCD; a new ‘‘Schizophrenia, Childhood Type’’, which included the following
disorder) in DSM-5 (APA, 2013), and to discuss the potential description: ‘‘the condition may be manifested by autistic, atypical
implications resulting from changes in the autism-related and withdrawn behavior’’. It was not until 1980s when the DSM
diagnoses in the DSM. shifted from psychological ‘‘states’’ described in DSM-II to discrete,
operationally defined disease categories in DSM-III. Pervasive
Developmental Disorders (PDD) was introduced as a new
diagnostic category in DSM-III. Four disorders were listed under
PDD – Infantile Autism, Childhood-Onset Pervasive Developmental
* Corresponding author at: Department of Psychiatry & Behavioral Sciences,
Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5717,
Disorder, Atypical Pervasive Developmental Disorder, Residual
United States. Tel.: +1 650 723 5511; fax: +1 650 723 2269. Infantile Autism, and Residual Childhood-Onset Pervasive Devel-
E-mail addresses: [email protected], [email protected] (L.K. Fung). opmental Disorder. In 1987, major changes in a number of

http://dx.doi.org/10.1016/j.ajp.2014.08.010
1876-2018/ß 2014 Elsevier B.V. All rights reserved.
94 L.K. Fung, A.Y. Hardan / Asian Journal of Psychiatry 11 (2014) 93–97

psychiatric diagnoses were made in DSM-III-R. The term ‘‘Perva- understanding relationships’’ in DSM-5. ‘‘Stereotyped/repetitive
sive Developmental Disorder’’ was retained. At the same time, language’’ in DSM-IV is now part of ‘‘stereotyped or repetitive
‘‘Autistic Disorder’’ was first introduced as a psychiatric diagnosis. motor movements, use of objects, or speech’’ in DSM-5.
The diagnoses ‘‘Infantile Autism’’ was dropped to recognize the fact ‘‘Persistent preoccupation with parts of objects’’ in DSM-IV is
that most individuals with autism continue to exhibit the disorder now included in the criteria ‘‘highly restricted, fixated interests’’.
after early childhood and the need for a more developmental The only truly new symptom criteria for ASD in DSM-5 is ‘‘hyper-
orientation to the diagnosis (Volkmar et al., 1988). ‘‘Childhood- or hyporeactivity to sensory input or unusual interest in sensory
Onset Pervasive Developmental Disorder’’, ‘‘Atypical Pervasive aspects of the environment’’, which is under stereotyped/
Developmental Disorder’’, ‘‘Residual Infantile Autism’’, and ‘‘Re- repetitive behaviors.
sidual Childhood-Onset Pervasive Developmental Disorder’’ were Although language development delay is not explicitly stated
also dropped in DSM-III-R. In 1994, DSM-IV was published. In as a diagnostic criterion, it is represented as a modifier. Other
addition to Autistic Disorder, four new diagnoses were included modifiers include intellectual impairment, association with a
under PDD – Asperger’s Disorder, Childhood Disintegrative known medical or genetic condition or environmental factor,
Disorder (CDD), Rett’s Disorder, and Pervasive Developmental association with another neurodevelopmental, mental, or behav-
Disorder-Not Otherwise Specified (PDD-NOS). DSM-IV-TR was ioral disorder, and presence of catatonia. In addition to modifiers,
published in 2000. The only change made to PDD was the narrative DSM-5 also includes definition of severity levels for both social
for Asperger’s Disorder, which was made in response to the communication deficits and repetitive/stereotypic behaviors.
dissatisfaction with the original description of the disorder Levels 1, 2, and 3 indicate ‘‘requiring support’’, ‘‘requiring
(Volkmar and McPartland, 2014). Finally, in May 2013, DSM-5 substantial support’’, and ‘‘requiring very substantial support’’,
was published. Asperger’s Disorder, CDD, and PDD-NOS were respectively.
subsumed by the new diagnosis of Autism Spectrum Disorder. In The new diagnosis of SCD is defined with four criteria: ‘‘deficits
the subsequent section, we discuss the changes from PDD to ASD, in using communication for social purposes in a manner that is
and their possible implications. appropriate for the social context’’, ‘‘impairment of the ability to
change communication to match context or the needs of the
2. DSM-5 changes listener’’, ‘‘difficulties following rules for conversation and
storytelling’’, and ‘‘difficulties understanding what is not explicitly
The DSM-IV-TR diagnostic criteria for Autistic Disorder defined stated and nonliteral or ambiguous meanings of language’’. In
3 domains of behavior – social deficits, communication deficits, order to fulfill the diagnosis of SCD, all four criteria have to be met.
and repetitive/stereotypic behaviors. Each domain contained 4 In addition to these specific changes/additions, a philosophical
symptoms. Under social deficits, the 4 criteria were ‘‘lack of social– change in DSM-5 is the idea of ‘‘living document’’. Instead of using
emotional reciprocity’’, ‘‘deficits in non-verbal communication’’, the Roman numeral ‘‘V’’ to label the 5th edition of DSM, an Arabic
‘‘lack of developing & maintaining relationships’’, and ‘‘lack of number ‘‘5’’ is used to symbolize that there will be updates of DSM-
spontaneous seeking to share interests’’. Under communication 5. Therefore, incremental updates will be identified with decimals,
deficits, the 4 criteria were ‘‘language development delay’’, i.e. DSM-5.1, DSM-5.2, etc., instead of waiting for the 6th edition of
‘‘impairment in initiating or sustaining conversation’’, ‘‘stereo- DSM to be released.
typed/repetitive language’’, and ‘‘lack of developmentally appro-
priate make-believe play’’. Under repetitive/stereotypic behaviors, 3. The field trials
the 4 criteria were ‘‘persistent preoccupation with parts of
objects’’, ‘‘stereotyped or repetitive behaviors’’, ‘‘insistence to Like DSM-IV, the diagnostic criteria in DSM-5 were assessed for
sameness’’, and ‘‘restricted interests’’. A total of six (or more) items, their feasibility, clinical utility, and reliability by field trials (Clarke
with at least two from social, and one each from communication, et al., 2013; Narrow et al., 2013; Regier et al., 2013). The DSM-5
and repetitive/stereotypic behaviors were needed to fulfill the field trials for ASD were conducted by using a test–retest reliability
criteria for Autistic Disorder. design with a stratified sampling approach across four pediatric
In DSM-5, ASD defined 2 behavioral domains – social sites in the United States. The DSM-5 field trials found that the
communication deficits and repetitive/stereotypic behaviors. DSM-5 criteria for ASD had very good reliability [intraclass
Under social communication deficits, there are three criteria – Kappa = 0.69; (Regier et al., 2013)]. However, there were some
‘‘deficits in social–emotional reciprocity’’, ‘‘deficits in non-verbal methodological limitations. First, these trials did not collect
communicative behaviors used for social interaction’’, and ‘‘deficits information regarding ASD diagnostic reliability for children under
in developing, maintaining and understanding relationships’’. age 6. In the clinical setting, diagnostic evaluations are done mostly
Under repetitive/stereotypic behaviors, there are four criteria – in children under age 6. Second, the field trials utilized data
‘‘stereotyped or repetitive motor movements, use of objects, or obtained from parental report alone. For cases with face-to-face
speech’’, ‘‘insistence of sameness or inflexible adherence to evaluations of children, only the highest functioning children
routines’’, ‘‘highly restricted, fixated interests’’, and ‘‘hyper- or participated in the interviews. Basic diagnostic evaluations for ASD
hyporeactivity to sensory input or unusual interest in sensory typically include interview and behavioral observations of
aspects of the environment’’. In order to fulfill the diagnosis of ASD, children, as well as interviews of the parents. Taken together,
all three social criteria, and at least 2 out of 4 symptoms in the the field trials for ASD had several methodological limitations and
stereotypic behaviors domain are needed. Unlike DSM-IV, DSM-5 future trials should account for these challenges for better
does not have specific age requirement for the onset of symptoms. acceptance and scientific validation.
A review of the new DSM-5 criteria reveals several changes.
‘‘Language development delay’’ in DSM-IV is not explicitly 4. Potential consequences to changes
covered by any DSM-5 criteria for ASD. The ‘‘lack of developing
& maintaining relationships’’ and ‘‘impairment in initiating or In a recent study, prevalence rates were determined retrospec-
sustaining conversation’’ criteria in DSM-IV are now included in tively by applying the DSM-5 criteria to population-based
the ‘‘deficits in social–emotional reciprocity’’ criteria in DSM-5. surveillance data collected for previous ASD prevalence estimation
The criteria ‘‘lack of developmentally appropriate make-believe (Maenner et al., 2014). Among the 6577 8-year-old children
play’’ is subsumed by ‘‘deficits in developing, maintaining and classified as having diagnoses of Autistic Disorder, Asperger’s
 L.K. Fung, A.Y. Hardan / Asian Journal of Psychiatry 11 (2014) 93–97 95

Disorder, or PDD-NOS based on the DSM-IV-TR, 5339 (81%) met Children with ASD experience many emotional, intellectual,
DSM-5 criteria for ASD. In contrast, only 304 children met DSM-5 physical, and social challenges, and it is crucial to facilitate a
ASD criteria but not DSM-IV PDD status. Before this study, 12 other healthy development of their identity and their sense of self. It is
studies employed a variety of methods studying populations with a unclear how DSM changes will affect this development. On one
large range of sample sizes. Among them, studies with more than hand, many individuals with Asperger’s Disorder and their families
500 participants included the following percentages of DSM-IV might have gone through a long and distressing process to accept
PDD subjects who met DSM-5 criteria: 52% (Matson et al., 2012), their diagnosis but now have to deal with replacing the diagnosis
61% (McPartland et al., 2012), 81% (Frazier et al., 2012), and 91% with a new diagnosis of ASD (Hazen et al., 2013). Indeed, some
(Huerta et al., 2012). A recent systematic review of 14 studies experts have continued to support having Asperger’s Disorder as a
revealed consistent decreases in ASD diagnosis using DSM-5 formal DSM diagnosis (Wing et al., 2011). On the other hand, some
compared to DSM-IV-TR criteria (Kulage et al., 2014). Furthermore, individuals in the Asperger community perceive the removal of
meta-analysis of these studies found that 22%, 70% and 70% of Asperger’s Disorder from the DSM as a positive change, as they see
individuals met criteria for diagnosis of Autistic Disorder, Asperger as a culture that should be supported and appreciated
Asperger’s Disorder and PDD-NOS, respectively, under DSM-IV- rather than diagnosed and treated (Vivanti et al., 2013). In any case,
TR but not for DSM-5 ASD criteria; however, results for Asperger’s it is expected that the use of Asperger’s Disorder to describe certain
Disorder were not statistically significant (Kulage et al., 2014). individuals will most likely continue, just like the term ‘‘high-
Finally, examining a large South Korean community sample functioning autism’’ (HFA) being commonly used despite the fact
(N = 55,266) of children from 7 to 12 years of age, Kim et al. that it was never in the DSM. However, it remains unclear if
found that most individuals with DSM-IV PDD met DSM-5 Asperger focused clinical activities such as treatment programs or
diagnostic criteria for ASD and SCD (Kim et al., 2014). Specifically, group therapy will continue to be available or not.
99% of children with autistic disorder, 92% of children with Finally, having fewer related diagnoses in DSM-5 (i.e. ASD and
Asperger’s Disorder (92%), and 63% of individuals with PDD-NOS SCD only) may minimize the confusion frequently reported by
met DSM-5 criteria of ASD, whereas 1%, 8%, and 32%, respectively, parents when they receive different diagnoses from different
met SCD criteria (Kim et al., 2014). Overall, the collective results clinicians. In the past 20 years, due to the presence of multiple
clearly concluded that the use of DSM-5 criteria would decrease autism spectrum diagnoses in DSM-IV (Autistic Disorder, Asper-
the prevalence of ASD. If we apply Maenner’s results to re-estimate ger’s Disorder, and PDD-NOS), many children who went through
the prevalence of ASD in 2010, the point prevalence will be 11.9 per multiple evaluations from multiple providers with different level
1000 or 1 in 83 [as compared to 14.7 per 1000 or 1 in 68 when of expertise in ASD might have received multiple diagnoses.
DSM-IV criteria was used (CDC, 2014)]. Therefore, this simplification may be a welcome change by families
Does the above evidence support that DSM-5 is more stringent and providers.
than DSM-IV? Preliminary evidence suggests a probable yes. Does
this result mean that autism was being over-diagnosed with DSM- 4.2. Impact on general practitioners
IV in the past? Or is autism being under-diagnosed with DSM-5?
This is a complex issue and will be dependent largely on how the One of the advances in DSM-5 is the clearer language in the
clinical ASD phenotype is defined. However, the dramatic increase diagnostic criteria of ASD, as well as the inclusion of more specific
in the prevalence of ASD in the past 40 years surely have direct examples to illustrate the criteria better. These concrete examples
impact on all stakeholders – patients, their families and friends, will help in educating general pediatricians, internists, and family
clinicians, and researchers. practitioners on what symptoms they should look for in the
evaluation of individuals with ASD. However, including examples
4.1. Impact on patients and their families of specific behaviors within criteria may reify the examples rather
than illustrating the underlying concept (Volkmar and McPartland,
First and foremost, DSM-5 states that individuals with a well- 2014). Furthermore, examples included in the DSM-5 criteria for
established DSM-IV diagnosis of Autistic Disorder, Asperger’s ASD appear to be more applicable for school age children and
Disorder, or PDD-NOS should be grandfathered in and will keep the adolescents than young children (i.e. infants, toddlers and
diagnosis of ASD. This is very important for patients and families preschoolers), and no information was provided on the expression
who need an autism diagnosis for services. Schools perform their of ASD symptoms in adults. As mentioned earlier, the reliability of
psychological evaluation in order to determine their students’ ASD as a diagnosis in DSM-5 was determined from data generated
special education categories, which are not part of the medical from research participants at age 6 and above, and the field trial did
diagnosis of ASD. Schools will continue to require evidence of not involve children under the age of 6 when most diagnosis of ASD
educational necessity as one of the key criteria for special are being made. Despite the lack of guidance in making ASD
education services. It is anticipated that school services for diagnosis for infants and toddlers in DSM-5, pediatricians are
students with ASD will not be affected. However, due to the obligated to screen for ASD in all children at 18 and 24 months, and
mounting economic pressures in many school districts, many at any time a parent raises a concern about ASD, as recommended
families have expressed concerns that the new ASD criteria might by the American Academy of Pediatrics (Myers and Johnson, 2007).
invite school districts to deny services given the high expenses of Given the subtlety of early signs of autism, it may be challenging
special education services (Halfon and Kuo, 2013). Furthermore, it for general pediatricians to make the diagnosis at early age without
remains unclear how insurance companies will adjust with the specialized training in ASD. Therefore, American Academy of
publication of DSM-5. Insurance companies in the U.S. use ICD-9 Pediatrics (AAP) has established toolkits for general pediatricians
codes to determine service coverage. The code for both Autistic in screening infants and toddlers for ASD (Johnson et al., 2007).
Disorder in DSM-IV and ASD in DSM-5 are the same (299.0).
Therefore, DSM changes should not affect the services covered 4.3. Impact on practitioners in autism specialty clinics
through insurance companies. This is particularly important in
several states in the U.S. where insurance companies are now Young children who meet DSM-5 criteria at an early age will
covering in-home behavioral interventions for children with ASD. benefit from a more comprehensive evaluation by early childhood
The real impact on service coverage might not be apparent until autism specialists. Specialty clinics for ASD typically employ a
few years from now. combination of clinical interviews of children and their parents,
96 L.K. Fung, A.Y. Hardan / Asian Journal of Psychiatry 11 (2014) 93–97

specific instruments for diagnosing autism [most commonly subtypes (King et al., 2014). In DSM-5, one important question for
Autism Diagnostic Observation Schedule (ADOS) and Autism researchers is to determine whether ASD and SCD are really
Diagnostic Interview – Revised (ADI-R)], and a battery of distinct disorders, with different developmental, biological and
neuropsychological testing to rule in or rule out diagnosis of prognostic characteristics. Some autism specialists have felt that
ASD. Autism specialists have more specific instruments for testing the DSM-5 criteria of SCD will capture individuals who would
younger and they are compatible with DSM-5. For example, ADOS- otherwise be diagnosed with either PDD-NOS or Asperger’s
T was designed for evaluating toddlers with autism. Focusing on Disorder per DSM-IV (Coury, 2013). Therefore final conclusions
the earliest manifestations of autism symptoms by utilizing a cannot be made before comprehensive research is completed to
sample of toddlers diagnosed with ASD, Guthrie et al. compared determine the validity of SCD.
the autism symptoms as measured by the ADOS-T in the 2-factor DSM-5 is designed to be a living document, so new evidence in
(social communication and repetitive/stereotypic behavior) model the understanding of the taxonomy and biology of ASD will help in
in DSM-5 with the 3-factor (social deficits, language deficits, and developing new characterization and classification of this disorder
repetitive/stereotypic behavior) model in DSM-IV, as well as two as well as SCD. The National Institute of Mental Health (NIMH) had
other models, and found that the components in ADOS-T are best already launched the Research Domain Criteria (RDoC) in
organized by the 2-factor structure in DSM-5 (Guthrie et al., 2013). classifying mental disorders based on dimensions of observable
Therefore, the changes from DSM-IV to DSM-5 appear to be behavior and neurobiological measures (Cuthbert and Insel, 2010;
consistent with the use of ADOS-T, a current gold standard Insel et al., 2010). RDoC is designed to be used for research
instrument employed in autism specialty clinics for diagnosing purposes at this time. The basic structure of RDoC consists of five
ASD in toddlers. neurobiological domains: positive valence systems, negative
In addition to confirming diagnoses of ASD, another major valence systems, cognitive systems, systems for social processes,
function of autism specialty clinics is to treat patients who need and regulatory/arousal processes. Each domain is then further
specialized care from specialists. These children and adolescents divided in two different dimensions: one dimension is the ‘‘Units of
typically have symptoms too difficult to be managed by parents Analysis’’, which include Genes, Molecules, Cells, Circuits, Physiol-
and/or general practitioners. Changes in DSM-5 are unlikely to ogy, Behavior, Self-Reports, and Paradigms; a second dimension is
impact the delivery of these specialized interventions because the ‘‘Constructs’’ and ‘‘Sub-constructs’’, which are the subtypes of
most providers in autism specialty clinics tend to be problem- the five neurobiological domains. While this is a promising
focused, evidence-based, and experience-driven. Although ASD is a approach in re-classifying mental disorders in a more comprehen-
new DSM diagnosis, this term has been used in 90% of the sive fashion, we do not know how the RDoC findings are going to
publications in the field of autism (King et al., 2014). Therefore, translate into clinical practice. Researchers and clinicians will need
autism specialists will be able to utilize the vast amount of to tackle this important problem, which will hopefully lead to a
evidence in the literature on ASD to support their clinical practice. paradigm shift not only in the field of autism but also in psychiatry
In contrast to ASD, SCD is a completely new diagnosis. Norbury in general.
argued that high rates of co-morbidity between SCD and other One final concern with the changes in the DSM is whether the
DSM diagnosis are anticipated and therefore raised questions new classification will affect subjects participating in research
regarding the clinical utility of this new diagnosis (Norbury, 2014). studies and most importantly the interpretation of studies that
Although preliminary evidence supports that pragmatic language have used previously published DSM criteria. Fortunately, it is
impairment in SCD is distinguishable from HFA by the absence of estimated that this impact is probably minimal on individuals with
stereotypic/repetitive behaviors (Gibson et al., 2013), this obser- Autistic Disorder since most recent and well-designed studies have
vation does not exclude the presence of a biological link between used the ADI-R and the ADOS as diagnostic instruments to confirm
ASD and SCD. Therefore, future research will be crucial to examine clinically made diagnosis. However, interpreting studies that have
the symptomatic, and pathophysiologic link between these included individuals with Asperger’s Disorder will be more
disorders. Questions will remain whether SCD is a milder form problematic with the absence of a clear continuity of this diagnosis.
of ASD, and some clinicians believe that individuals meeting Therefore, the inclusion of a specifier in DSM-5 ASD diagnostic
diagnostic criteria of SCD might fulfill diagnosis of either PDD-NOS criteria that describes the presence or not of early developmental
or Asperger’s Disorder (Coury, 2013). For those individuals who do history of language delay will allow the characterization of
not fulfill diagnostic criteria for ASD and SCD but suffer from social individuals who use to be diagnosed with Asperger’s Disorder
communication deficits and/or repetitive/stereotypic behaviors, and differentiate them from HFA (individuals with ASD and normal
they may either receive no DSM-5 diagnosis or have a new IQ). This will allow investigators who are still interested in
diagnosis of Unspecified Neurodevelopmental Disorder (UND). investigating Asperger’s Disorder to conduct study using DSM-5
Similar to children with ASD, those with SCD and possibly UND also criteria. More importantly, this specifier will permit clinicians to
need support in social pragmatics and clinical program and school characterize more accurately individuals previously diagnosed
districts should develop appropriate interventions to optimize the with Asperger’s Disorder using the DSM-5 framework and ease the
functioning of these individuals and help with their deficits in frustration of a group of experts about eliminating this diagnosis
social pragmatics. from the new version of DSM.

4.4. Impact on autism research 5. Conclusions

ASD is a complex, heterogeneous disorder with numerous The field of autism has certainly evolved dramatically since
etiologies. Finding the best approach to classify ASD has been a Kanner’s first description of autism 70 years ago. Although
holy grail in autism research for over 30 years, ever since DSM-III scientific progresses in the field are rapid in the past 20 years,
first described autism as a distinct diagnosis. Classifying patients in they do not support the classification of the discrete autism
subtype categories carries a mandate that the individual subtypes subtypes in DSM-IV. The new DSM-5 diagnostic criteria of ASD
will have their own distinct developmental trajectories, prognoses reflect the advances in the field’s understanding of the condition in
and specific treatment options. DSM-IV was a clear attempt in that communication is part of social processes and that sensory
classifying autism diagnoses by symptom clustering, but it has not aberrations are extremely common. The four DSM-IV PDD
resulted in strong evidence of discrimination among the five diagnoses (i.e. Autistic Disorder, Asperger’s Disorder, CDD, and
 L.K. Fung, A.Y. Hardan / Asian Journal of Psychiatry 11 (2014) 93–97 97

PDD-NOS) are now subsumed by ASD in DSM-5. Individuals with Gibson, J., Adams, C., Lockton, E., Green, J., 2013. Social communication disorder
outside autism? A diagnostic classification approach to delineating pragmatic
ASD are now described with the new specifiers in the core language impairment, high functioning autism and specific language
symptom severity, other functional domains (intellectual im- impairment. J. Child Psychol. Psychiatry 54, 1186–1197.
pairment, language impairment), and associated conditions Guthrie, W., Swineford, L.B., Wetherby, A.M., Lord, C., 2013. Comparison of DSM-IV
and DSM-5 factor structure models for toddlers with autism spectrum disorder.
(medical or genetic conditions; another neurodevelopmental, J. Am. Acad. Child Adolesc. Psychiatry 52, 797–805, e792.
mental, or behavioral disorder). While these specifiers are Halfon, N., Kuo, A.A., 2013. What DSM-5 could mean to children with autism and
extremely helpful in the clinical setting, the chronology of specific their families. JAMA Pediatr. 167, 608–613.
Hazen, E.P., McDougle, C.J., Volkmar, F.R., 2013. Changes in the diagnostic
symptoms is not included in the current version of DSM-5. criteria for autism in DSM-5: controversies and concerns. J. Clin. Psychiatry
Specifically, history of developmental language delays and history 74, 739–740.
of regression of social and communication abilities will be helpful Huerta, M., Bishop, S.L., Duncan, A., Hus, V., Lord, C., 2012. Application of DSM-5
criteria for autism spectrum disorder to three samples of children with DSM-
to categorize certain individuals with ASD. Finally, individuals who
IV diagnoses of pervasive developmental disorders. Am. J. Psychiatry 169,
have social communication deficits without clinically significant 1056–1064.
repetitive behaviors/restricted interests may now receive a new Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D.S., Quinn, K., Sanislow, C.,
diagnosis of SCD or no diagnosis at all. Although clinicians may use Wang, P., 2010. Research domain criteria (RDoC): toward a new classification
framework for research on mental disorders. Am. J. Psychiatry 167, 748–751.
UND for those individuals who do not fulfill the diagnostic criteria Johnson, C.P., Myers, S.M., American Academy of Pediatrics Council on Children
for both ASD and SCD diagnoses, it is unclear what the implication With Disabilities, 2007. Identification and evaluation of children with autism
of receiving this diagnosis and more importantly the practical spectrum disorders. Pediatrics 120, 1183–1215.
Kim, Y.S., Fombonne, E., Koh, Y.J., Kim, S.J., Cheon, K.A., Leventhal, B.L., 2014. A
implications on the services that these individuals will need. Comparison of DSM-IV pervasive developmental disorder and DSM-5 autism
Overall, the changes in diagnostic criteria for autism have affected spectrum disorder prevalence in an epidemiologic sample. J. Am. Acad. Child
and will continue to affect the lives of many patients and their Adolesc. Psychiatry 53, 500–508.
King, B.H., Navot, N., Bernier, R., Webb, S.J., 2014. Update on diagnostic classification
families, as well as the work by clinicians and researchers in the in autism. Curr. Opin. Psychiatry 27, 105–109.
field of autism. As a living document, DSM-5 is expected to Kulage, K.M., Smaldone, A.M., Cohn, E.G., 2014. How will DSM-5 affect autism
incorporate the latest scientific advances, and will continue to diagnosis? A systematic literature review and meta-analysis. J. Autism Dev.
Disord. 44, 1918–1932.
evolve. Maenner, M.J., Rice, C.E., Arneson, C.L., Cunniff, C., Schieve, L.A., Carpenter, L.A., Van
Naarden Braun, K., Kirby, R.S., Bakian, A.V., Durkin, M.S., 2014. Potential impact
Acknowledgments of DSM-5 criteria on autism spectrum disorder prevalence estimates. JAMA
Psychiatry 71, 292–300.
Matson, J.L., Hattier, M.A., Williams, L.W., 2012. How does relaxing the algo-
The authors would like to thank Drs. Carl Feinstein and Jennifer rithm for autism affect DSM-V prevalence rates? J. Autism Dev. Disord. 42,
Philips for helpful discussions on DSM-5. Dr. L.K. Fung is supported 1549–1556.
McPartland, J.C., Reichow, B., Volkmar, F.R., 2012. Sensitivity and specificity of
by the National Institute of Mental Health (Grant no. MH019908- proposed DSM-5 diagnostic criteria for autism spectrum disorder. J. Am. Acad.
19) through the Ruth L. Kirschstein Individual Postdoctoral Child Adolesc. Psychiatry 51, 368–383.
National Research Service Award (T-32). Myers, S.M., Johnson, C.P., 2007. Management of children with autism spectrum
disorders. Pediatrics 120, 1162–1182.
Narrow, W.E., Clarke, D.E., Kuramoto, S.J., Kraemer, H.C., Kupfer, D.J., Greiner, L.,
References Regier, D.A., 2013. DSM-5 field trials in the United States and Canada, part III:
development and reliability testing of a cross-cutting symptom assessment for
APA, 2013. Diagnostic and Statistical Manual of Mental Disorders: DSM-5, fourth DSM-5. Am. J. Psychiatry 170, 71–82.
ed. American Psychiatric Association, Washington, DC. Norbury, C.F., 2014. Practitioner review: social (pragmatic) communication disor-
CDC, 2014. Prevalence of autism spectrum disorder among children aged 8 years – der conceptualization, evidence and clinical implications. J. Child Psychol.
autism and developmental disabilities monitoring network, 11 sites, United Psychiatry 55, 204–216.
States, 2010. Morbil. Mortal. Wkly. Rep.: Surveill. Summ. 63, 1–21. Regier, D.A., Narrow, W.E., Clarke, D.E., Kraemer, H.C., Kuramoto, S.J., Kuhl, E.A.,
Clarke, D.E., Narrow, W.E., Regier, D.A., Kuramoto, S.J., Kupfer, D.J., Kuhl, E.A., Kupfer, D.J., 2013. DSM-5 field trials in the United States and Canada, part II:
Greiner, L., Kraemer, H.C., 2013. DSM-5 field trials in the United States and test–retest reliability of selected categorical diagnoses. Am. J. Psychiatry 170,
Canada, part I: study design, sampling strategy, implementation, and analytic 59–70.
approaches. Am. J. Psychiatry 170, 43–58. Vivanti, G., Hudry, K., Trembath, D., Barbaro, J., Richdale, A., Dissanayake, C., 2013.
Coury, D.L., 2013. DSM-5 and autism spectrum disorders: implications for families Towards the DSM-5 criteria for autism: clinical, cultural, and research implica-
and clinicians. J. Dev. Behav. Pediatr. 34, 494–496. tions. Austral. Psychol. 48, 258–261.
Cuthbert, B.N., Insel, T.R., 2010. Toward new approaches to psychotic disorders: the Volkmar, F.R., McPartland, J.C., 2014. From Kanner to DSM-5: autism as an evolving
NIMH Research Domain Criteria project. Schizophr. Bull. 36, 1061–1062. diagnostic concept. Annu. Rev. Clin. Psychol. 10, 193–212.
Frazier, T.W., Youngstrom, E.A., Speer, L., Embacher, R., Law, P., Constantino, J., Volkmar, F.R., Bregman, J., Cohen, D.J., Cicchetti, D.V., 1988. DSM-III and DSM-III-R
Findling, R.L., Hardan, A.Y., Eng, C., 2012. Validation of proposed DSM-5 criteria diagnoses of autism. Am. J. Psychiatry 145, 1404–1408.
for autism spectrum disorder. J. Am. Acad. Child Adolesc. Psychiatry 51, 28–40, Wing, L., Gould, J., Gillberg, C., 2011. Autism spectrum disorders in the DSM-V:
e23. better or worse than the DSM-IV? Res. Dev. Disabil. 32, 768–773.