Current Psychiatry Reports

, Volume 14, Issue 6, pp 739–747 | Cite as

What the DSM-5 Portends for Research, Diagnosis, and Treatment of Autism Spectrum Disorders

Autism Spectrum Disorders (D Mandell, Section Editor)


In May 2013 the APA will release DSM-5, which will restructure the diagnostic classification for autism spectrum disorders (ASDs) into a single category. The proposed changes in DSM-5 aim to better reflect the current state of research by consistently identifying the core features in social/communication and restrictive and repetitive behaviors that are specific to ASDs. This review describes the empirical and theoretical bases of research in the nosology of ASDs, given the impending shift in DSM-5 diagnostic criteria. General issues in diagnosis and prevalence are described, with differences between DSM-IV and DSM-5 highlighted. To address concerns about the application of the proposed DSM-5 criteria, the current literature assessing the sensitivity and specificity of the proposed DSM-5 criteria is reviewed. Last, we discuss the implications of the changes in DSM-5 for the treatment of ASDs and recommend areas for future research.


Autism Autism spectrum disorders ASD DSM-5 Diagnosis Prevalence Treatment Education Research Psychiatry 


Almost 70 years of research and clinical practice have led to a better understanding of the clusters of symptoms associated with autism spectrum disorders (ASDs). Leo Kanner was the first to use the term “autism” in its modern sense [1] to describe 11 children with unusual behavior similarities. Several traits he described in the children, including “autistic aloneness,” and “insistence on sameness,” form the essential criteria in current conceptualizations of ASD. In the decades since Kanner’s work, researchers have continued to describe and redefine these behaviors [2, 3, 4]. Though diagnostic frameworks have expanded and contracted – resulting in changes in prevalence rates – actual behavioral descriptions have steadily become more precise and at the core, many of the symptoms have remained the same.

Below, we review prevalence rates of ASDs, with a focus on issues of variability in diagnosis. Second, the proposed DSM-5 criteria are described and differences between existing criteria and the revised dimensions for diagnoses are examined. Third, we review selected studies from the past year providing support for or criticism of the new diagnostic criteria proposed in DSM-5. Finally, we look at the implications of the new conception of diagnosis in regard to treatment and future directions for research.

Current Diagnosis of Autism

In the absence of known biomarkers for ASDs, diagnoses are based on a core set of behavioral features, often noticed before a child’s second birthday. Typically, a diagnosis is made through obtaining behavioral history as well as observing the child using standardized clinical tools [5]. Currently, most researchers use measures such as the Autism Diagnostic Interview-Revised [6] or the Diagnostic Interview for Social and Communication Disorders [7] to obtain early developmental history from parents, along with semi-structured, standardized observations such as the Autism Diagnostic Observation Schedule [8] or the Screening Tool for Autism in Toddlers and Young Children [9] to make diagnostic decisions. Clinicians, at least in North America, often use the observational instruments or may use broader screening tools such as the Childhood Autism Rating Scale [10]. Using a combination of these standardized instruments, a reliable and valid diagnosis can be made by the age of 2 [2, 11, 12, 13]. These sources of information allow clinicians to generate an overall clinical impression, based on all available sources of information, which then corresponds with a diagnostic classification from either the DSM-IV or ICD-10.

There is still substantial variability in community practice in the methods used to make an ASD diagnosis, particularly a diagnosis of autism versus Asperger’s syndrome or PDD-NOS. Both use of standardized instruments and actual diagnosis vary based on the context of the diagnosis (medical, educational, administrative), region where the assessment is conducted, and the person giving the diagnosis. This variability can lead to differences in observed prevalence, as well as inconsistent classification of individuals within the autism spectrum [14].


Once thought to be relatively rare, with rates of 4.1/10,000 individuals [15] diagnosed with autism, recent studies have found rates of the whole autism spectrum at around 70/10,000 [16]. One study even reported rates as high as 181/10,000 [17]. In late March of this year, the Centers for Disease Control (CDC) released prevalence rates from data collected by the Autism and Developmental Disabilities Monitoring (AADM) Network in 2008. Diagnostic decisions were made from reviewing all available (medical, educational) evaluation records per child, and matching case histories to DSM-IV-TR diagnostic criteria for an ASD. These data found that, across 14 ADDM sites (encompassing a total of 337,093 children), 1 in 88 eight-year old children met research criteria for an ASD [18]. The reported increase of nearly 23 % from 2006 garnered much media attention. In reality, it seems likely that some of the increase may be due to increased awareness of ASDs, different definitions of ASDs, as well as differences in access to services, all of which can contribute to differences in prevalence rates [16].

That observed local resources can drive prevalence and practices is exemplified by the different regional prevalence rates within the ADDM data. For example, Alabama, with an estimated poverty rate of 23 %, had the lowest prevalence rate of 4.8 in 1000, whereas Utah, with only a 16 % estimated poverty rate, had nearly four times Alabama’s observed ASD prevalence of 21.2 in 1000 [18, 19]. The dramatic difference between these two states can likely be attributed to both access to healthcare the amount of available statewide resources to make an ASD diagnosis. Studies have found that factors such as number of medical clinics and community health centers are associated with rates of autism diagnosis [20, 21]. Additionally, autism diagnoses have been positively associated with high socioeconomic status [22, 23, 24, 25] likely because of the implications for increased levels of parental education or access to health care.

The ADDM study drew data from both medical and educational records, which may also have contributed to the regional variation in diagnoses. Studies using medical diagnoses, educational diagnoses or a combination of the two can result in inconsistent rates of identification because the educational definition of autism differs from the medical definition [26]. For example, in a 2008 record review in Utah, ASD prevalence rates significantly differed when using an educational diagnosis versus a medical diagnosis [27]. States differ on whether Asperger’s syndrome and PDD-NOS are eligible for special education under the autism category. Thus, a child may have a medical diagnosis of PDD-NOS, but reside in a state where the behaviors associated with PDD-NOS would not be enough to be eligible for an educational classification of autism. Moreover, educational eligibilities are determined using different methods and criteria than medical diagnoses. Currently, there are no consistent screening and assessment procedures used across state and district educational settings to determine eligibility [28, 29]. Consequently, the financial resources of a school district (e.g., the ability to staff and train school psychologists and to purchase diagnostic tools) may determine their ability to make an accurate diagnosis [21, 30, 31, 32].

Overall, prevalence rates provide information about rates and methods of identification in ASDs. However, there is considerable variability in how a diagnosis is made in different contexts, which makes it difficult to interpret trends in prevalence and compare studies. Further, often in both educational and research settings, different rates of prevalence can result from inconsistent application of the DSM-IV categories of PDD subtypes.

Variability in ASD Diagnoses

A recent study by Lord and colleagues [31], which included 2102 children with ASD across 12 university-based autism centers, found that the distribution of children’s behaviors was similar; however the distributions of clinical best estimate diagnoses (autism, Asperger’s Syndrome, PDD-NOS) were dramatically different across site. Even when using the same diagnostic instruments and standardized procedures across sites, there was regional variability in which ASD diagnosis was given to a child (autism, Asperger’s syndrome, PDD-NOS). The most important factors predicting best estimate diagnoses within the autism spectrum were: scores from the Autism Diagnostic Observation Schedule (ADOS) [8] and the site where the diagnosis was given. Although the characteristics of the children were similar, clinicians used non-ASD specific behavioral characteristics (e.g., hyperactivity), age and IQ to make diagnoses of autism, Asperger’s syndrome or PPD-NOS. For example, some sites gave children with higher IQs a diagnosis of Asperger’s syndrome, while other sites used PDD-NOS. In one site, children of more educated mothers were more likely to get an Asperger’s diagnosis, even after controlling for the characteristics of the children.

This study provides compelling evidence that the model of ASDs in the DSM-IV does not provide enough diagnostic clarity [33] in how Asperger’s syndrome and PDD-NOS are distinguished. Thus, variability in observed prevalence may also be a function of categorical inconsistency, emphasizing the need for clearer diagnostic criteria to guide clinicians in making reliable decisions.


The American Psychiatric Association’s (APA) Diagnostic Statistical Manual (DSM) guides clinical decisions and diagnoses of mental disorders. Until 1980, autism was not included in the DSM. Both the first (1952) and the second (1968) editions of the DSM use the terms, “autism” and “autistic” to describe behaviors manifested by Schizophrenia. In 1980, DSM-III introduced the term, “Infantile Autism,” which was later expanded to, “Autistic Disorder” in DSM-III-R [34]. However, DSM-III-R criteria were criticized for their low specificity [35]. This was one concern informing the changes in DSM-IV.

DSM-IV Diagnosis

Autistic disorder (DSM-IV-TR: 299.00) is one of five pervasive developmental disorders described in DSM-IV-TR, referred to here as ASDs. The remaining four include: Rett’s disorder (299.80), childhood disintegrative disorder (299.10), Asperger’s disorder (299.80), and pervasive developmental disorder-not otherwise specified (299.80). Currently, DSM-IV-TR outlines ASD as a triad of qualitative impairments in social interaction, communication and restricted, repetitive and stereotyped behaviors. For an individual to meet criteria for an ASD, delays or abnormal functioning must be evident in at least one area associated with autism (e.g., social interaction, communication or restricted and stereotyped behaviors) before the age of three. For an autism diagnosis, individuals must meet at least two criteria in the social interaction domain, at least one criterion in the communication domain, and at least one criterion in the restricted behaviors domain [36]. The approach of requiring only one or two out of several possible criteria in the triad of impairments defined in DSM-IV-TR leads to the construction of many different patterns of development; some have suggested that these criteria are overly inclusive and confusing [37].

Specifically, there is wide variability in how Asperger’s syndrome is diagnosed. Some clinicians base the distinction on whether or not a child had a language delay, however it is not always possible to have an accurate report of when a child began speaking in single words and phrases [33]. Additionally, in DSM-IV, the intention was for an Asperger’s syndrome diagnosis to only be given if criteria for autistic disorder were not met. Unfortunately, this does not happen consistently. Several recent studies have shown that a high proportion of children and adults with diagnoses of Asperger’s syndrome meet criteria for autism [35, 38••, 39, 40].

Second, not otherwise specified, “NOS” codes were never intended to be used as common diagnoses; however in some epidemiological studies, PDD-NOS has been diagnosed more frequently than autistic disorder [41, 42]. In the recent CDC surveillance report [43] approximately one quarter of children with ASD had received at least two different ASD-subtype diagnoses by age 8. How accurate are descriptions of a disorder when atypical presentations are more commonly diagnosed than typical ones [44]? The proposed model of a unified ASD diagnosis in DSM-5 is an attempt to better describe individuals by identifying the social-communication core features consistently associated with all individuals with ASD, as well as clarifying and expanding conceptualizations of restricted, repetitive behaviors and interests.

DSM-5 Diagnosis

The unified ASD category proposed by DSM-5 aims to produce a clear diagnostic system that will identify the common characteristics of ASDs across all ages and ability levels [33]. To describe this single category, the triad of impairments will be merged into a dyad: social/communication and restrictive and repetitive interests. In DSM-IV, criteria reflect examples from multiple levels of analyses, including specific behaviors such as shared enjoyment, general qualities such as social reciprocity and important contexts such as peer interactions. In contrast, DSM-5 identifies a smaller number of more general principles in social communication. These principles are expected to be present in all individuals with ASD regardless of age and developmental level, but can be manifested in many different ways.

Consequently, in the social/communication domain, 3 out of 3 criteria must be endorsed for an ASD diagnoses. The restricted, repetitive behaviors domain includes four general types of sensory-motor and cognitive examples of repetition and restriction, two of which must be endorsed for an ASD diagnosis. This will include insistence on sameness, which has been reinstated from Kanner’s original paper and DSM-III-R. This area could be particularly important to characterize individuals across the lifespan, who may not have “typical” restricted, repetitive behaviors (e.g., hand flapping, spinning) but have difficulty with changes in routine and schedule, both of which affect their overall level of functioning. One area in this domain that previously has not been included in any version of DSM diagnostic criteria is hypo-and-hyper sensory reactivity or interests [45]. This consideration of the environment is important to include in diagnosis, as it can provide important information to guide treatment. The behaviors in this domain do not have to be present; they may have been present only in history. DSM-5 will also include specified severity levels, defined by level of support needed for individual functioning [45]. Both intellectual functioning and language level will determine these severity levels, thus will now be important considerations in an ASD diagnosis. Characterizing the severity in ASDs may provide a more precise way to describe individuals and document changes that may occur as a result of treatment and/or development.

The DSM-5 will include a new diagnosis, “pragmatic (social) communication disorder,” to describe the rare individuals who display significant social/communication impairments of ASDs without restrictive/repetitive behaviors. Research suggests that most children and adults who have DSM-IV PDD-NOS or Asperger syndrome diagnoses will have sufficient restricted, repetitive behaviors by history or currently, using the expanded number of types of behaviors in DSM-5, to meet criteria for ASDs [46••]. Thus, the pragmatic (social) communication disorder will allow treatment of individuals with only social and/or pragmatic difficulties.

The proposed changes in DSM-5 offer a number of positive changes. The new criteria leave room for the inclusion of important factors that should be considered in both research and treatment. These include the presence of environmental features, intellectual functioning, language level, severity of autistic symptomology and overall impairment. Further, a single category of ASDs moves the focus of those making diagnoses to the identification of deficits in social/communication and restrictive and repetitive behaviors as characteristic of all ASDs, rather than distinguishing among various forms of ASDs.

Sensitivity and Specificity of DSM-5

Any change in how a disorder is diagnosed and conceptualized has the potential to affect changes in research of the disorder. While the DSM aims to integrate research into diagnosis, researchers have an obligation to continue to examine how diagnostic criteria will affect individuals with ASD and whether the guidelines for a diagnosis are effectively identifying those with the disorder. Fortunately, this past year has resulted in much research on the impact of proposed diagnostic changes [46••, 47]. Several articles, describing samples from across the world, published from 2011-present are summarized in Table 1.
Table 1

Recent studies comparing DSM-IV and DSM 5



Data source


Mean age (years)

Mean IQ

Dx measure

Specificity/sensitivity of DSM-5

Frazier et al. [52] (2012)

United States


8,911 ASD


Not reported



5,863 non-ASD siblings

Mandy et al. [51] (2012)

United Kingdom


488- ASDs

9.6 (3.6)




220 Broader Phenotype



Huerta et al. [46••] (in press)

North America

SSCb, CPEAc, Clinic

4,453 PDD


84.8(2.61), 83.3(26.6),



690 non-PDD


Gibbs et al. [53] (2012)



132 ASD



Clinical judgment based on ADOSh/ADI-Rg


McPartland et al. [47] (2012)

United States


657 ASD



DSM- IV Field Trial Checklist


276 non-ASD

9.5 (8.2)

> 85

Taheri & Perry [54] (2012)



93 Autistic disorder



CARSi, Vinelandj



Worley & Matson [68] (2012)

United States


121 ASDs


Not reported

Symptom checklists


Mattila et al. [48] (2011)


Epidemiological cohort

61 ASD



AASQk/DSM-IV,5 criteria/ADOSh/ADI-Rg


21 no ASD

aInteractive Autism Network

bSimons Simplex Collection

cCollaborative Programs of Excellence in Autism

dSocial Responsiveness Scale

eSocial Communication Questionnaire

fDevelopmental, Dimensional and Diagnostic Interview

gAutism Diagnostic Interview-Revised

hThe Autism Diagnostic Observation Schedule

iChildhood Autism Rating Scale

jVineland Adaptive Behavior Scales

kAutism Spectrum Screening Questionnaire

Considerable media attention has been paid to the possibility that the unification of ASDs into one disorder may leave many individuals currently diagnosed with ASD without a diagnosis [47, 48, 49]. Notably, one study [47] caused quite a dramatic media response, when the researchers implied that the new DSM-5 criteria for ASDs would exclude 39 % of individuals carrying various DSM-IV PDD diagnoses. In response to this article, the DSM workgroup offered an editorial raising concerns about methodological flaws in the study [50]. Specifically, the data were collected in the 1993 field trials of DSM-IV, so the individuals in the study were initially identified by clinical diagnoses based on DSM-III-TR criteria [34]. Because the only data available were current DSM-IV items and not the expanded examples available for DSM-5, there was insufficient information to determine the history of restrictive and repetitive behaviors, which may have been why many individuals were seemingly missed.

A major concern raised from this study [47] and from the autism community is: are the new criteria too restrictive to identify Asperger’s syndrome and PDD? Recent studies both assuage this concern and suggest that there is not ample empirical evidence to separate it from autistic disorder [38••, 40]. For example, a recent study encompassing a sample of 4453 children with PDD, found that 91 % of children with a PDD diagnosis in DSM-IV would retain that diagnosis using DSM-5 criteria [46••]. In fact, using parent report the characteristics of ASDs have been found to map better to the DSM-5 dyad across age groups and IQ levels, than the DSM-IV-TR triad [51]. Utilizing large samples, researchers also found the sensitivity of DSM-5 to be quite high with adequate specificity [46••, 52]. These studies provide support for the shift to a unified diagnostic category of ASDs, which will be able to accurately identify the common features specific to ASDs.

A few recent studies have suggested that when applying the proposed DSM-5 criteria to individuals with a current ASD diagnosis, between 75-80 % would retain their DSM-IV diagnoses [53, 54]. However, small sample sizes, and methods of diagnoses limit the interpretability of these findings, specifically whether the DSM-5 criteria are actually missing a quarter of those currently diagnosed with an ASD. Further, many of the individuals that were “missed” in these studies, failed to meet criteria because of lack of sufficient restrictive and repetitive behaviors [51]. These may be individuals that would meet criteria for pragmatic (social) communication disorder. Another important issue to consider when interpreting these studies, is that DSM-IV was widely criticized for being over inclusive [55]. Thus some individuals with a DSM-IV diagnosis may have had impairments, such as specific language impairment or intellectual disability, that were erroneously diagnosed as a PDD. Overall, it is difficult to determine how the change in diagnostic criteria proposed by DSM-5 will actually affect rates of diagnosis and access to services, until these new criteria as well as the pragmatic (social) communication disorder diagnosis are consistently applied. More research is needed to understand whether individuals will be truly missed by the new DSM-5 criteria, or if the real implications of these studies are that methods of diagnoses guided by DSM-5 are now more precise in identifying ASDs.

Kapp and Ne’eman [56] raise concerns about how the changes in DSM-5 will affect adolescents and adults in obtaining an ASD diagnosis. Often, these individuals have developed coping skills that make them appear more socially adept in assessment situations than they are in typical environments. However, DSM-5 leaves room for individual variation in the range of examples that can be generated for each domain, which allows for the inclusion of subtle differences in social/communication. Conversely, meeting the restrictive and repetitive behavior domain of the new diagnostic criteria may be problematic for adults. In the absence of these behaviors, a historical report of their presence in childhood is sufficient [57]. However, older adults may not have living parents or relatives who can provide this historical information. Research is needed about adults with ASD to better understand current patterns of behavior that can be used to provide diagnostic clarity in the absence of early history.


Having described the new DSM-5 criteria and compared them to those in DSM-IV, we can now consider the impact these changes will have. DSM-5 will affect several dimensions, including access to services, education and broader policy. There are two separate, but overlapping areas to consider in treatment: medical and educational. Each of these areas will be discussed in reference to the new DSM-5 criteria.

Pertinent to guiding medical treatments, a change in DSM-5 is that ADHD, one of the most common co-morbidities of developmental disorders [58, 59], now can be separately diagnosed along with ASD. Presently, pharmaceutical interventions, specifically stimulants, are the most common treatment for ADHD [59, 60], though behavioral interventions may also provide benefits [61]. Many individuals with ASDs and ADHD have been shown to benefit from pharmaceutical interventions [59]. Positive outcomes associated with pharmaceutical interventions include improvement in executive functioning and reduction in stereotypy, aggressive behaviors and irritability [59, 62]. The inclusion of co-morbid ADHD and ASD in a DSM-5 diagnosis can allow those treating these children to separately consider and treat ADHD symptoms with medication and specific behavioral interventions. For example, impulsive behaviors and poor emotional inhibition, specific to ADHD may affect an individuals’ ability to effectively form peer relationships [60]. This could be particularly social debilitating for a child who also has difficulty with peer relationships because of ASD-specific deficits in nonverbal communication, reciprocity, and play. A child with ADHD and ASD may benefit from parent training to improve emotional regulation [63] and medication to improve attention, before receiving social skills training to promote peer relations.


A concern has also been raised about the possibility of children losing special education services as a result of the impending changes in DSM-5 [64]. It is important to note that the current definition for autism under the Individuals with Disabilities Education Act (IDEA [65]) is not based on DSM-IV criteria, and in fact aligns more clearly with DSM-5 criteria. The current federal definition for autism under IDEA is as follows:

A developmental disability significantly affecting verbal and nonverbal communication and social interaction, usually evident before age 3 that adversely affects a child’s educational performance. Other characteristics often associated with ASD are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences [65].

Special education determinations are not necessarily the same as a diagnosis. States do not have to follow federal guidelines, thus there is considerable variability from state to state in how special education determinations are made. Each state has a specific definition of autism built into their education code. For example, in California, the first section of the code reads, “a ‘pupil with autism’ is a pupil who displays autistic-like behaviors,” and continues to broadly describe seven behaviors that may present in any combination for a student to have an educational diagnosis of autism. The state of New York also has a broadly inclusive definition of autism, both of these being less stringent than DSM-IV or DSM-5 criteria. Even in a state like Oregon, which has highly specific criteria to determine an educational eligibility, the definition of autism is actually well aligned with DSM-5 criteria. In Oregon, for a child to have an educational determination of autism, a developmental profile must provide evidence, in the form of both observational assessments and historical report, of impairments in communication, social interaction, restrictive and repetitive behaviors and unusual sensory responses. It would be surprising if states developed more stringent criteria following DSM-5, given that it is often easier to meet an educational definition of autism than that defined by the DSM-4.

In fact, the categorization of ASD as a single disorder may even have positive implications for individuals receiving special education services. In order to be eligible for special education services, students must fall under one of 14 federally designated disability categories. Currently, only autism is recognized as a disability category eligible for special education services. This has sometimes resulted in those with Asperger’s syndrome or PDD-NOS being denied special education services and subsequent supports [38••, 66••]. Under DSM-5, those who may have previously received a PDD-NOS or Asperger’s syndrome diagnosis could now have a medical diagnosis of autism. What is unclear, however, is how the new “pragmatic (social) communication disorder” will factor into special education eligibility. It has been suggested that it may align with the federal “specific language impairment” category [66••]; however, it is difficult to project the impact of this change.


Over the past decade, there has been a considerable increase in the amount of autism research. In the United States alone, the number of publications has increased nearly four-fold [67]. Although there have been several studies examining DSM-5 criteria, there are still inconsistencies in prevalence rates across regions, even within the United States, and uncertainty about how to best apply diagnostic criteria to adults. Thus, we recommend some primary areas on which to focus research efforts:
  • Determine factors that account for variations in prevalence, including sociopolitical, medical and diagnostic.

  • Develop ways of separating symptom severity from functional impairment.

  • Better delineate the types of comorbidities with ASD (e.g., ADHD) and how they affect and are affected by development.

  • Identify current patterns of social/communication deficits and restrictive and repetitive behaviors in adults with ASDs. This will improve the ability to make a diagnosis in the absence of reports of early history.


The single category of autism spectrum disorder proposed by DSM-5 [45] aims to provide a more precise definition of autism spectrum disorders that will guide consistent diagnoses across medical, educational, and service organizations [50]. DSM-5 provides improved specificity compared to DSM-IV, and is more tied to empirical studies of the organization of deficits then DSM-IV [38••]. Yet, a common theme has emerged through this review: variability. There is variability in prevalence rates, variability between educational and medical diagnoses, variability in diagnostic applications of PDD-NOS and Asperger’s syndrome, and even variability in the research aiming to understand how DSM-5 will be applied to different presentations of ASDs. This variability is one of the most perplexing and fascinating aspects of autism. We hope that the new DSM-5 criteria will provide a more specific framework to guide diagnosis, prevalence, treatment and research, while continuing to acknowledge the heterogeneity of this disorder both across individuals and within individuals over time.

Perhaps one of the most poignant statements Kanner [1] made when describing the children in his case study, was that they were, “[children] whose condition differs so markedly and uniquely from anything reported so far, that each case merits . . . a detailed consideration of its fascinating peculiarities” (p. 217). Thus, we do not expect DSM-5 to perfectly describe the individual nuances of every individual. Rather, we hope that DSM-5 and research data will support those working with individuals with ASDs in their recognition of the common features of ASD, in order to provide diagnoses that can guide both treatment and research.



S. Mahjouri: research support from National Institute of Child Health & Human Development (NICHD) and Simons Foundation; C.E. Lord: research support from National Institute of Mental Health, Health Resources and Services Administration, NICHD, and Simons Foundation, and royalties from Western Psychological Services.


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Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.PsychiatryWeill Cornell Medical CollegeWhite PlainsUSA

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