An Autism Spectrum Disorder (ASD) diagnosis is often used to access services. We investigated whether ASD diagnostic outcome varied when DSM-5 was used compared to ICD-10R and DSM-IV-TR in a clinical sample of 150 intellectually able adults. Of those diagnosed with an ASD using ICD-10R, 56 % met DSM-5 ASD criteria. A further 19 % met DSM-5 (draft) criteria for Social Communication Disorder. Of those diagnosed with Autistic Disorder/Asperger Syndrome on DSM-IV-TR, 78 % met DSM-5 ASD criteria. Sensitivity of DSM-5 was significantly increased by reducing the number of criteria required for a DSM-5 diagnosis, or by rating ‘uncertain’ criteria as ‘present’, without sacrificing specificity. Reduced rates of ASD diagnosis may mean some ASD individuals will be unable to access clinical services.
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Funding was provided by the Medical Research Council (MRC, UK), the EU Autism Imaging Study (AIMS) network (Grant Agreement: 115300), and the National Institute for Health Research Biomedical Research Centre for Mental Health at King’s College London, Institute of Psychiatry and South London and Maudsley National Health Service Foundation Trust. The authors wish to thank all the participants involved in this study. Also the administrative support staff at the Behavioural Genetics Clinic: Frances Harwood, Pauline Domingo and Marie Simpson.
Francesca Happé and Professor Declan Murphy are joint senior authors.
Francesca Happé is part of the DSM-5 workgroup on neurodevelopmental disorders.
ICD-10R algorithm, with corresponding DSM-IV-TR items provided alongside each criterion. Of the participants that were diagnosed with ASD on the ICD-10R, the proportion of participants that were coded ‘Yes’, ‘No’ and ‘Unclear’ for each item is given.
|ICD-10R Algorithm (Corresponding DSM-IV item provided for each criterion).||ICD-10R: ASD positive group|
|1 Qualitative abnormalities in reciprocal social interaction are manifest in at least two of the following areas:||Yes||No||Unclear|
a. Failure adequately to use eye-to-eye gaze, facial expression, body posture, and gesture to regulate social interaction|
DSM-IV-TR: 1a: Marked impairment in the use of multiple nonverbal behaviours such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction.
b. Failure to develop (in a manner appropriate to mental age, and despite ample opportunities) peer relationships that involve a mutual sharing of interests, activities, and emotions|
DSM-IV-TR: 1b: Failure to develop peer relationships appropriate to developmental level
c. Lack of socio-emotional reciprocity as shown by an impaired or deviant response to other people’s emotions; or lack of modulation of behaviour according to social context; or a weak integration of social, emotional, and communicative behaviours|
DSM-IV-TR: 1d: Lack of social or emotional reciprocity
d. Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g. a lack of showing, bringing, or pointing out to other people objects of interest to the individual).|
DSM-IV-TR: 1c: a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
|2. Are there restricted, repetitive patterns of behavior, interests, and activities, as manifested by at least one of the following:||Yes||No||Unclear|
a. A delay in, or total lack of, development of spoken language that is not accompanied by an attempt to compensate through the use of gesture or mime as an alternative mode of communication (often preceded by a lack of communicative babbling);|
DSM-IV-TR: 2a: delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
b. Relative failure to initiate or sustain conversational interchange (at whatever level of language skills is present), in which there is reciprocal responsiveness to the communications of the other person|
DSM-IV-TR: 2b: in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
c. Stereotyped and repetitive use of language or idiosyncratic use of words or phrases|
DSM-IV-TR: 2c: stereotyped and repetitive use of language or idiosyncratic language
d. lack of varied spontaneous make-believe or (when young) social imitative play|
DSM-IV-TR: 2d: lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
|3. Restricted, repetitive, and stereotyped patterns of behaviour, interests, and activities are manifest in at least one of the following areas:||Yes||No||Unclear|
a. An encompassing preoccupation with one or more stereotyped and restricted patterns of interest that are abnormal in content or focus; or one or more interests that are abnormal in their intensity and circumscribed nature though not in their content or focus|
DSM-IV-TR: 3a: encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus.
b. Apparently compulsive adherence to specific, non-functional routines or rituals|
DSM-IV-TR: 3b: apparently inflexible adherence to specific, nonfunctional routines or rituals
c. Stereotyped and repetitive motor mannerisms that involve either hand or finger flapping or twisting, or complex whole body movements|
DSM-IV-TR: 3c: stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements)
d. Preoccupations with part-objects or non-functional elements of play materials (such as their odor, the feel of their surface, or the noise or vibration that they generate).|
DSM-IV-TR: 3d: persistent preoccupation with parts of objects
DSM-5 algorithm indicating the proportion of participants diagnosed with ASD on the ICD-10R that were coded ‘Yes’, ‘No’ and ‘Unclear’ for each item. Criteria from ICD-10R that contribute to each DSM-5 criterion are indicated, and underlined sections indicate sections not explicitly in ICD-10R criteria.
ASD positive group
|Criteria from ICD-10R||CRITERION A: Are there persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by ALL THREE of the following:||Yes||No||Unclear|
|2b; 1c; 1d||1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation/through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction?||94.7||1.8||3.5|
|1a;||2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures?||80.5||13.3||6.2|
|1b; 2d (but must be shared imaginative play)||3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people?||93.8||2.7||3.5|
|CRITERION B: Are there restricted, repetitive patterns of behavior, interests, and activities, as manifested by AT LEAST TWO of the following:||Yes||No||Unclear|
|2c; 3c; 3d||1. Stereotyped or repetitive speech, motor movements, or use of objects (such as, simple motor stereotypies and echolalia, repetitive use of objects, or idiosyncratic phrases)?||54.9||33.6||11.5|
|2c; 3b||2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change (such as, motoric rituals, insistence on same route or food, repetitive questioning, or extreme distress at small changes)?||57.5||25.7||16.8|
|3a; 3d||3. Highly restricted, fixated interests that is abnormal in intensity or focus (such as, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests)?||66.4||22.1||11.5|
|3d||4. Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment (such as, apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects)?||18.6||31.0||50.4|
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Wilson, C.E., Gillan, N., Spain, D. et al. Comparison of ICD-10R, DSM-IV-TR and DSM-5 in an Adult Autism Spectrum Disorder Diagnostic Clinic. J Autism Dev Disord 43, 2515–2525 (2013). https://doi.org/10.1007/s10803-013-1799-6
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