Is avoiding eye contact a sign of autism? What about lining up toys, repeating the same words over and over, or getting extremely upset if the routine is broken? All of those things may well be there, but again, none of those on their own is diagnostic of autism. That’s where the DSM-5 autism diagnostic criteria come in.
Clinicians look at five key areas (differences in social communication, repetitive behaviors, early developmental signs, and the impact on daily life). So what does it actually mean in practice for a child? This guide takes you through each of the five areas with real-world examples, explains the three levels of autism support, and tells you what professionals look for during the assessment.
What are the DSM-5 diagnostic criteria for autism?
Doctors who specialize in autism will use the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) as their diagnostic guide. That’s the standard text psychiatrists use to assess developmental differences. They issued a revised edition in 2022 (the DSM-5-TR) to clarify some of the language in the diagnostic criteria.
A child needs to meet requirements across five main criteria to receive a diagnosis, as outlined in the CDC’s diagnostic criteria:
- Criterion A: Differences in all three areas of social interaction/communication.
- Criterion B: 2 or more of the 4 types of restricted/repetitive behaviors, interests, or activities.
- Criterion C: Signs that originated in the early developmental period, even if they only became apparent later.
- Criterion D: Characteristics which cause significant difficulty in everyday functioning.
- Criterion E: Traits that are not better explained by intellectual disability or global developmental delay.
Criterion A: Social Communication and Social Interaction Differences
This is the first criterion, which looks at the way one relates to others. For this criterion, a person must show differences in all three of the following:
Differences in Social-Emotional Reciprocity
This section is about sharing back and forth. Young kids may not be the ones to bring their toys to you to share their interests; they may react differently to a smile. Small talk with older children and adults can be awkward, and if they’re a bit emotional, they may find it very difficult to express themselves, or they may go on and on about something they love that the other person has, quite frankly, lost interest in.
Differences in Nonverbal Communication
This includes body language, facial expressions, and the use of eye contact. A child may use far fewer gestures (e.g., waving, pointing) to share something of interest with others. Children with non-verbal autism may rely on gestures or other forms of communication instead of spoken words. Their eye contact may also be different from what we’re used to. Eye contact by itself is not diagnostic of autism; it’s one of the features that doctors will take into account.
Difference in Developing and Understanding Relationships
This looks at the mechanisms of socialization and the maintenance of social relationships. A child may have problems joining in with other children in make-believe play, may not behave the same way in group games, or may have difficulty in adapting their behavior to different social situations. Deep, meaningful friendships can exist between autistic people, although they may take a different form.
Criterion B: Restricted or Repetitive Behaviors and Interests
The second key requirement relates to actions, routines, and sensory needs. The child must show characteristics in at least two of the four areas (either in the present or in their developmental history):
- Repetitive movements, speech or object use: Hand flapping, rocking of the body, echolalia (repeating words over and over again) or repeatedly lining up toys.
- Strong preference for routines and sameness: Distressed by minor changes to the schedule; requires the same sequence of steps every day; very rigid in thought.
- Highly focused or intense interests: Some extremely intense or narrow interest in a particular facet of a hobby, for example train timetables, details on maps, or specific animals.
- Sensory differences: Strong response to sensory input (e.g., bright lights, loud noises, clothing tags, etc.) or reduced sensitivity to pain/temperature. Some children may also be seeking out intense sensory experiences or activities (e.g. spinning).
Criterion C: Autism Characteristics Start Early in Development
The traits need to be present from an early age, although they may not become apparent until later in life as the social pressures of school come into play. Older children, teens, and adults can sometimes learn coping mechanisms that mask the traits. That’s why clinicians will invariably ask parents about early developmental milestones and the child’s behavior as a young child.
Criterion D: Characteristics Significantly Affect Everyday Functioning
To be diagnosed, the traits must cause clinically significant difficulty in everyday functioning (in school, in friendships, in daily life, etc.). The impact will vary depending on the noise, activity level, and/or stress level in a particular environment. It does not reflect the child’s intelligence or value. It simply describes the impact of the characteristics on important areas of functioning.
Criterion E: Autism Is Not Explained by Intellectual Disability Alone
Autism and intellectual disability (or global developmental delay) can occur together, but they are distinct conditions. The rule is that a child’s social communication differences will be more than would be expected for their general developmental level. A speech delay in itself does not mean a child has autism, which is why a child’s communication and overall developmental level are both assessed during the evaluation.
What are the three autism severity levels in the DSM-5?
The manual categorizes support needs into three levels. These are not direct measures of intelligence or future potential; rather, they describe the level of support required in relation to social communication and restricted/repetitive behaviors. The three severity levels of ASD are as follow:
- Level 1 (Requires support): The individual requires support. Without support, there may be significant difficulties in social communication, and they may find it very difficult to switch from one activity to another.
- Level 2 (Requiring substantial support): The person will require substantial support. Social communication will be impaired even with support, and restricted or repetitive behavior may impact everyday functioning.
- Level 3 (Requiring very substantial support): The person requires very substantial support. Significant social communication difficulties and restricted or repetitive behaviors substantially impact everyday functioning.
Doctors rate the child on social communication and on repetitive behaviors separately, and the ratings can change as the child gets older.
How do professionals go about diagnosing autism using the DSM-5 criteria?
There is absolutely no such thing as an online autism quiz that can result in a diagnosis. That kind of assessment requires a skilled and thorough clinical evaluation by a properly qualified clinician. The clinician may be a developmental pediatrician, a child psychologist, a neurologist, or an appropriately trained GP.
An autism assessment may include:
- In-depth discussions with parents regarding the child’s developmental history and behavior.
- Watching the child playing and getting involved in the activities.
- Assessing communication, developmental and sensory responses.
- Hearing and vision assessments where appropriate to identify any condition that may be contributing to a developmental or communication difficulty.
Can a child have autistic traits without meeting all the DSM-5 criteria?
Yes. Some kids may have some of the features associated with autism without meeting all the criteria for a diagnosis of autism. A doctor might make a diagnosis of Social (Pragmatic) Communication Disorder in a child who has the sort of social communication difficulties seen in autism, but who doesn’t have the restricted and repetitive behaviors that are required for an autism diagnosis.
Kids can still be eligible for speech or occupational therapy without an autism diagnosis. It depends on the individual child and their needs, as well as the eligibility criteria of the service or insurance provider.
How are the DSM-5 autism criteria different from the DSM-IV criteria?
Before 2013, the older manuals had separate labels for Autistic Disorder, Asperger’s Disorder, and PDD-NOS. Under the new guidelines, these have all been subsumed into a single diagnosis of Autism Spectrum Disorder. Under the new guidelines, a doctor will still diagnose ASD but will add specific notes to reflect the individual’s level of language and learning. An individual who had a well-established DSM-IV diagnosis of Autistic Disorder, Asperger’s Disorder, or PDD-NOS should be diagnosed with Autism Spectrum Disorder under the DSM-5.
What’s the difference between the DSM-5 and the DSM-5-TR autism criteria?
The DSM-5-TR came out in 2022 to clarify text descriptions, including the wording of certain diagnostic criteria. The main autism-related update clarified that a person must meet all three social communication requirements under Criterion A. This adjustment reflects the original diagnostic intent and helps reduce ambiguity in how clinicians interpret the criteria.
Conclusion
Learning about the autism diagnostic criteria in the DSM-5 is a practical step toward getting clear answers for your child. These medical standards give doctors a clear roadmap to understand your child’s strengths and support needs accurately.
Every child grows at their own pace, and getting an official evaluation can help identify your child’s developmental needs and guide recommendations for appropriate support. At BrightSteps ABA, we provide personalized ABA therapy to help children build essential skills and independence.
