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FEATURE

Healio.com/Pediatrics | 161

PEDIATRIC ANNALS 42:4 | APRIL 2013

DSM-5 and Proposed Changes
to the Diagnosis of Autism

W. David Lohr, MD; and Peter Tanguay, MD

When the American Psychiatric
Association releases the
Diagnostic and Statistical
Manual of Mental Disorders, fifth edition
(DSM-5) next month, children currently
diagnosed with autism may lose access
to services. Modifications to the proposed
criteria have been suggested to address
concerns of sensitivity.

IMPLICATIONS OF DSM-5

The American Psychiatric Association�s
stated goals for the changes to its diagnostic
criteria for autism spectrum disorder
(ASD) in DSM-5 are to �accurately and
completely identify� individuals with autism
by production of reliable and valid diagnostic
criteria1 in order to offer a clearer,
simpler, more reliable diagnostic scheme
and recognize the �essential shared features
of the autism spectrum.�2 This means
that, for the clinician, it should be easier to
diagnose ASD than trying to distinguish
between high-functioning autism (HFA)
and Asperger�s disorder. In addition, the
vague diagnosis of pervasive developmental
disorder not otherwise specified
(PDD-NOS) has been replaced, in part, by
social communication disorder (SCD) (see
Table 1, page 162).

Questions have already been raised
about the appearance of a new diagnosis,
SCD, that describes children with difficulties
in the pragmatics of verbal and nonverbal
communication, leading to impaired
social function. This disorder excludes an
autism diagnosis, and thus rules out the
presence of restrictive, repetitive behaviors
(RRBs);3 however, SCD seems to resemble
mild autism or PDD-NOS.4,5 Questions
remain about how the criteria for SCD will
be implemented, and whether children who
meet criteria for SCD will meet eligibility
for medical and educational services.6

Overall, the changes should result in
more reliable and valid diagnoses, with
estimates of individual severity and associated
conditions. It will remain important
for clinicians to take a thoughtful and
complete history and combine information
from multiple sources with clinical observation
to diagnose children with ASD with
improved specificity.

For clinicians and families, the singular
question is whether the new criteria will
change access to treatment and/or educational
services. Studies have noted that individuals
with a diagnosis of Asperger�s disorder
or PDD-NOS, those with higher IQ,
and female patients may be at most risk.4
This could impact whether children with
an established DSM-IV diagnosis of Asperger�s
disorder or PDD-NOS would need

W. David Lohr, MD, is Assistant Professor of
Pediatrics, Division of Child & Adolescent Psychiatry
and Psychology; Associate in the Department
of Psychiatry and Behavioral Sciences;
and Co-Clinical Director, University of Louisville
Autism Center, University of Louisville School
of Medicine. Peter Tanguay, MD, is the Spafford
Ackerly Endowed Professor of Child and Adolescent
Psychiatry (Emeritus) in the Department of
Psychiatry and Behavioral Sciences, University of
Louisville School of Medicine.

Address correspondence to: W. David Lohr,
MD, University of Louisville Autism Center, 200
E. Chestnut Street, Louisville, KY 40202; fax: 502-
852-1055; email: wdlohr01@louisville.edu.

Disclosure: The authors have no relevant financial
relationships to disclose.

doi: 10.3928/00904481-20130326-12

� Shutterstock

FEATURE

162 | Healio.com/Pediatrics

PEDIATRIC ANNALS 42:4 | APRIL 2013

re-evaluation per the DSM-5 criteria. The
question then becomes whether insurance
companies and educational systems continue
to accept these diagnoses for coverage.

Improved ability to identify a more homogenous
group of ASD should help those
researching the condition by improving
the ability to detect etiologies, endophenotypes,
genetic markers, and by strengthening
treatment and outcome data. Yet,
questions remain about how the proposed
changes will affect the compatibility of future
research with prior research and how
the criteria will mesh with International
Classification of Diseases, eleventh revision
(ICD-11) standards.7

HISTORY OF AUTISM IN THE DSM

Although autism was first described by
Kanner in 1935,8 it was not considered a
formal psychiatric diagnosis until the release
of DSM-III in 1980.9 In this system,
to be diagnosed with autism, individuals
had to meet all diagnostic criteria (monothetic)
and the categories described a condition
similar to classical autism.4,9

In the 1987 DSM-III-R version, a subset
with a range of criteria (polythetic) could
be applied during diagnosis, leading to a
more heterogeneous diagnostic group10
DSM-IV, published in 1994 (see Table 2,
page 163), has continued the polythetic
approach.11 To meet the diagnostic criteria,
patients must meet a minimum of six
behavioral criteria subsets: two from social
impairment; one from communication; and
one from RRBs. Also, the onset of the condition
must be prior to age 3 years.

Introduction of Asperger�s Disorder

The DSM-IV requires that for an Asperger�s
disorder diagnosis, the patient
meet a minimum of three criteria: two from
social impairment and one from RRB. Asperger�s
disorder differs from autism in that
there can be no communication impairment
or delay in language, and no age of onset
by 3 years. Also, there can be no delay in
cognitive development or nonsocial adaptive
behavior. DSM-IV criteria for PDD-
NOS are for subthreshold presentations of
autistic symptoms featuring impairment
in social or communicative functioning or
RRB (see Table 2, page 163).

Concerns about the DSM-IV and ASD

Questions about how the DSM-IV addresses
ASD led to revisions in the DSM-
5. First, the number of possible symptom
combinations in the DSM-IV has been estimated
to be 2,027, with inherent heterogeneity
of the diagnostic group.4 Concerns
exist also with its reliability and validity. In
a recent multisite study of 2,102 probands,
the best-estimate clinical diagnoses were
compared with those from standardized
diagnostic instruments.12

Experts differed on how they interpreted
DSM-IV criteria, even though the
reliability of the data from the standardized
interviews was good. Patterns of
diagnosis were identifiable according to
regional sites, with factors such as verbal
IQ and language level influencing the
process.

Also, research has not identified meaningful
differences between DSM-IV-text
revision (published in 2000) subtypes of
ASD controlled for IQ and language.13
In particular, Asperger�s disorder is not
thought to be distinct from HFA with little
support of DSM-IV distinction.2,14,15

TABLE 1.

Comparison of Autism Criteria in DSM-IV and DSM-5

DSM-IV

DSM-5

A. (1) a. marked impairment in the use of multiple nonverbal aspects of social interaction

A. (1) b. failure to develop appropriate peer relationships

A. (1) c. lack of spontaneous sharing with other people

A. (1) d. lack of social or emotional reciprocity

A. (2) a. delay or lack of spoken language

A. (2) b. impaired ability to initiate or sustain a conversation

A. (2) c. stereotypical and repetitive language

A. (2) d. lack of make-believe or imitative play

A. (3) a. stereotypical and restricted patterns of interest

A. (3) b. inflexible adherence to rituals or routines

A. (3) c. stereotypical and repetitive motor movements

A. (3) d. persistent preoccupations with parts of objects

None

B. delays in at least one of three areas with onset prior to age 3 years of social interaction, language used as
(1) social communication, (2) symbolic or (3) imaginative play, or (4) hyper-or hypo-reactivity to sensory input

A1 and A3 with onset in early childhood

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Diagnostic Challenges of Asperger�s
Disorder

Asperger�s disorder is difficult to diagnose
using DSM-IV criteria because
accurately measuring language delays
retrospectively is a challenge, as is clinically
distinguishing these patients from
those with autism.2 In addition, Asperger�s
disorder diagnoses have been
shown to be unreliable between expert
clinicians.12 It is also important to note
children with autism who met language
milestones before the age of 3 years may
have the same adult outcome as those
children with autism who did not.16

The DSM-IV criteria also have been
faulted with how well they diagnose autism
in children younger than 5 years,
adolescents, females, and ethnic minority
groups.1 These concerns with the limitations
of DSM-IV have been raised over the
last 20 years by researchers in the area of
diagnosis and classification of autism spectrum
disorders and have prompted the development
of the criteria found in DSM-5.

CHANGES IN THE DSM-5

In the DSM-5, autism, Asperger�s disorder,
and PDD-NOS will be combined into
a single category of ASD6 and supplemented
with a dimensional aspect for assessing
the level of dysfunction. This is important
because social communication function
appears to be distributed in a continuous
fashion across the general population.17,18

In particular, the domains for social and
communication problems have been combined
into one set of deficits, labeled,�social
communication and interactive problems.�
The set of symptoms for restricted, repetitive
interests remains, but unusual sensory
behaviors have been added to their diagnostic
set.

The DSM-5�s approach to social communication
symptoms is monothetic, requiring
that individuals meet all criteria
from the social-communicative set; for
RRB, the DSM-5 is polythetic, requiring
that two of four symptoms be present. In
all, five of seven symptoms must be present
in the DSM-5, compared with six of 12
symptoms required by the DSM-IV (see
Table 3, page 164).

The deficits in communication and
social behaviors were combined into one
domain because the Autism Work Group
of the DSM-5 Committee believed the two
represent a similar impairment.5 Because
a delay in language is not believed to be
unique or universal in ASD, this criterion
is eliminated altogether.

The requirement for two symptom sets
for repetitive behaviors and fixated interests
by history or direct observation is
thought to increase the stability of the diagnosis
of ASD over time. The criteria now
include symptoms for abnormal sensory
behaviors. This improves the relevance of
the criteria to younger children with ASD,
because sensory issues are common concerns
in this population.

The development of the DSM-5 has
been based on literature review, expert
consultations, work group discussions,
and secondary analysis of data sets. As
noted, making the diagnosis should be

TABLE 2.

Diagnostic Criteria for
Autistic Disorder from DSM-IV

A. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from
(2) and (3):

(1) Qualitative impairment in social interaction, as manifested by at least two of the following:

(a) marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze,
facial expression, body posture, and gestures to regulate social interaction;

(b) failure to develop peer relationships appropriate to developmental level;

(c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other
people, (eg, by a lack of showing, bringing, or pointing out objects of interest to other people); and

(d) lack of social or emotional reciprocity (note: in the description, it gives the following as
examples: not actively participating in simple social play or games, preferring solitary activities,
or involving others in activities only as tools or �mechanical� aids).

(2) Qualitative impairments in communication as manifested by at least one of the following:

(a) 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) in individuals with adequate speech, marked impairment in the ability to initiate or
sustain a conversation with others;

(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to
developmental level.

(3) Restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested
by at least two of the following:

(a) encompassing preoccupation with one or more stereotyped and restricted patterns of
interest that is abnormal either in intensity or focus;

(b) apparently inflexible adherence to specific, nonfunctional routines or rituals;

(c) stereotyped and repetitive motor mannerisms (eg, hand or finger flapping or twisting, or
complex whole-body movements);

(d) persistent preoccupation with parts of objects.

B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age
3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or
imaginative play.

C. The disturbance is not better accounted for by Rett�s disorder or childhood disintegrative
disorder.

Source: American Psychiatric Association11

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easier for the pediatrician since the criteria
are designed to promote more agreement
between clinicians.

EVIDENCE FOR AND AGAINST
DSM-5 CHANGES

Several studies have been conducted
to determine how DSM-5 changes will
affect the ASD population. Mattila et al19
compared DSM-IV criteria with early draft
criteria for the DSM-5 in 82 individuals
derived from an epidemiological sample
of 5,484 8-year-olds. The DSM-5 group
was less sensitive for HFA (IQ > 70) and
Asperger�s disorder, but the group was an
earlier version later updated by the Neurodevelopmental
Disorders Workgroup. For
patients with HFA, 73% were identified
by the DSM-5 but none of 11 subjects with
Asperger�s disorder were identified using
the DSM-5 criteria.

The study�s authors suggested five
modifications to relax the DSM-5 criteria
and create a �mild� version of autism compared
with the �strict version� identified
by the DSM-5. After the authors modified
the DSM-5 criteria, 96% of overall subjects
were identified. No information is offered
on effects of specificity.19

Supporting evidence was provided by
Mandy et al20 who reported that the DSM-
5 offered improved construct validity over
DSM-IV-TR by improving the criteria language
and by the inclusion of hyper- and
hyposensory abnormalities as part of the
symptoms cluster.

In a large analysis of siblings by Frazier
et al21 from the Interactive Autism Network,
8,911 siblings were found to have
ASD; 5,863 did not. Compared with the
DSM-IV TR, the proposed criteria show
greater specificity to reduce false-positive
diagnoses but slightly lower sensitivity so
more false-negative diagnoses may result,
especially with females.

Frazier et al21 proposed relaxing the
DSM-5 criteria by requiring one less symptom
criteria of SCI or RRB to increase sensitivity
by 11% to 12%. This may be very
pertinent for those diagnosed with Asperger�s
disorder or those youth whose early life
symptoms are not easily obtained. Overall,
the study�s superior specificity validated
the DSM-5.21

However, different conclusions were
found by McPartland et al4 in a sample of
933 subjects from a previous DSM-IV field
trial of which 657 were diagnosed with
ASD. This group was evaluated with proposed
DSM-5 criteria and sensitivity and
specificity were measured. In this group,
60.6% of ASD cases meet revised DSM-
5 criteria for ASD with a specificity of
94.9%. Those with IQ > 70 and Asperger�s
disorder were less likely to be diagnosed
according to the DSM-5. For example, the
sensitivity of the DSM-5 criteria to diagnose
ASD in DSM-IV cases of Asperger�s
disorder was only 25%. They concluded
the new criteria could have detrimental
clinical and research effect. Others have
questioned the validity of their findings
given the historical data and methods.1

Matson and colleagues22,23 have published
several studies comparing the DSM-
IV with the DSM-5 and conclude the proposed
changes will lead to 30% to 45% of
children, adolescents, and adults classified
with ASD per DSM-IV-TR to not meet criteria
for ASD with DSM-5.

The most recent study to date estimated
how many children diagnosed with PDD
or non-PDD using the DSM-IV-TR will
no longer meet the necessary criteria for
ASD under DSM-5. Using data from 4,453
children with a clinical PDD diagnosis,

TABLE 3.

DSM-5 Proposed Criteria for Autism Spectrum Disorders

A. 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:

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.

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.

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.

B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two
of the following:

1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor
stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).

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).

3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment
to or preoccupation with unusual objects, excessively circumscribed or perseverative
interests).

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).

C. Symptoms must be present in early childhood (but may not become fully manifest until social
demands exceed limited capacities)

D. Symptoms together limit and impair everyday functioning.

Source: American Psychiatric Association5

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and from 690 children with a non-PDD diagnosis,
data from the Autism Diagnostic
Interview, Revised (ADI-R) and Autism
Diagnostic Observation Schedule (ADOS)
was matched to the DSM-5 criteria. In this
study, it was found that most children who
received a diagnosis of one of the PDDs
under the DSM-IV would receive the diagnosis
of ASD under the DSM-5.23

The overall sensitivity of the two were
similar: the DSM-5 criteria identified 91%
of children with a clinical DSM-IV diagnosis
of PDD, with no change based on gender
or IQ. The specificity was improved in
the DSM-5, especially when impairment in
social reciprocity and nonverbal behavior
was required in both the parent report and
the clinical observation. Children who did
not meet the DSM-5 criteria did not demonstrate
required impairments in social and
communication functioning.24 To date, data
from studies on the effectiveness of ASD
diagnostic criteria have been retrospective.
The most stringent have used diagnostic instruments
based on the DSM-IV; however,
the two studies with the largest sample size
show the highest levels of sensitivity for
DSM-5 (see Table 4).

CALLS FOR MODIFICATION
OF DSM-5

Modifications to the DSM-5 criteria
already have been suggested to address
these concerns of sensitivity. In addition
to the proposals to reduce the criteria for
social communication and interaction from
three to two,4,19,21,23,24 there have also been
proposals to change the number of RRB
criteria from two to one.13,23 Another theory
is that relaxing the onset criteria may
improve the ability to detect early social
interaction problems, thus improving sensitivity.
19,25 These changes would likely
increase sensitivity while maintaining acceptable
specificity.4,21

Work on the DSM-5 continues, and as
it nears publication more accurate estimates
of sensitivity and specificity will be
measured as criteria will be compared in
vivo against DSM-IV criteria and the �gold
standard� of expert diagnosis. Community
and clinical populations will be assayed
to provide current measures of sensitivity
and specificity.1

TABLE 4.

Studies Comparing Diagnosis of ASD in DSM-IV and DSM-5

Study / year

Number of Subjects

Type of Sample

Instruments Used

Results

Limitations

Mattila et al19 / 2011

Screened epidemiological
sample
diagnosed with DSM-
IV criteria

ADI-R, ADOS, early DSM-
5 criteria

DSM-5 was less sensitive
than DSM-IV for ASD,
(0.46)

Early DSM-5 criteria,
prevalence for
PDD-NOS was not
examined

Mandy et al20 / 2012

708

Consecutive referrals
to an autism specialty
clinic

3Di

DSM-5 model was superior
to DSM-IV

Higher functioning
sample, 3Di is a DSM-
IV derived tool

Frazier et al21 / 2012

14,744 siblings
(8,911 with autism)

Family-selected
internet registry

Mapped caregiver rated
SRS and SCQ to DSM-5
criteria

DSM-5 had lower sensitivity,
(0.81 vs. 0.95) but
greater specificity, (0.97
vs. 0.86) than DSM-IV

Early DSM-5 criteria,
self-selected sample,
reliance on caregiver
reports only

McPartland et al4 /
2012

933 (657 diagnosed
with ASD)

Multicenter DSM-IV
field trial database,
with clear reliability
data

Algorithm of items
from DSM-IV mapped to
match DSM-5 criteria

60.6% of cases with ASD
met DSM-5 criteria with
a specificity of 94.9%

Included only 48
DSM-IV subjects with
Asperger�s disorder,
modified a historical
data set to new criteria

Matson et al22,23 /
2012

2,721 toddlers aged
17-36 months

EarlySteps participants

Clinical judgment using
diagnostic algorithms

52.2% of toddlers were
diagnosed with ASD by
DSM-5

Single author review
of evaluations based
on DSM-IV

Gibbs et al13 / 2012

132 youth

Referred to tertiary
autism clinic for initial
evaluation

ADOS, ADI-R

76.5% of participants
were diagnosed with
ASD by DSM-5

ADOS and ADI-R are
DSM-IV based tools

Taheri and Perry33
/ 2012

131 children aged
2-12 years

Retrospective file
review

CARS, DSM-IV checklist

62.6% of total sample
met diagnosis of ASD by
DSM-5

No Asperger�s disorder
patients, DSM-5
criteria were evaluated
by checklist

Huerta et al24 / 2012

5,143 subjects,
4453 had PDD

Data sets from family
genetics study,
university and autism
center databases

ADI-R and ADOS
matched to DSM-IV and
DSM-5 criteria. Included
parent report and/or
direct observation

DSM-5 identified 91%
of children with PDD
diagnoses. Overall specificity
was low, (0.53) but
improved over DSM-IV

More severe clinical
sample, retrospective
data analysis

3Di = Developmental, Dimensional, and Diagnostic Interview; ADI-R = Autism Diagnostic Interview, ADOS = Autism Diagnostic Observation Schedule; ASD = autism spectrum disorder; CARS = Childhood
Autism Rating Scale; NOS = not otherwise specified; PDD = pervasive developmental disorder; Revised; SCQ = Social Communication Questionnaire; SRS = Social Responsiveness Scale.

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PEDIATRIC ANNALS 42:4 | APRIL 2013

Because it places primary focus on social
communication problems, continued
interest will explore the boundaries of normal
and abnormal social communication.
This is relevant because autistic traits appear
to have some continuous dimension within
a population.18 The field will need suitable
instruments to measure social communication
skills and determine distribution in the
population, assign cutoff points, operationalize
mild and moderate impairment, and
measure adaptive function.6

CONCLUSION

Philosophical questions, such as whether
autism is a single, continuous entity
marked by impaired social interaction, will
still exist after publication of the DSM-5.
Some will point out the broad distribution
of autistic symptoms in the population26
and elevated rates in twins and siblings.
18,27 Conversely, there is the question
of whether autism is a diverse collection
of heterogeneous conditions with a shared
group of symptoms. Then there are those
who see autism as a collection of different
syndromes and who point out that latent
or emerging symptoms differentiate ASD
from non-ASD children,28 a point of view
supported by data on trajectory of brain
development.29 The contrast between the
two groups is impetus for improved understanding
of autism. The DSM-5 fits squarely
in the middle of these discussions.30

The DSM-5 is the next evolutionary
step for the diagnosis of autism based on
the empirical input of the last 20 years of
nosology and epidemiology.31,32 As with
all diagnostic systems, it is a work in progress
and is the best attempt so far to describe
autism as we understand it today.

REFERENCES

1. Swedo SE, Baird G, Cook EH, Jr., et al. Commentary
from the DSM-5 Workgroup on Neurodevelopmental
Disorders. J Am Acad Child
Adolesc Psychiatry. Apr 2012;51(4):347-349.

2. Happe F. Criteria, categories, and continua:
autism and related disorders in DSM-
5. J Am Acad Child Adolesc Psychiatry.
2011;50(6):540-542.

3. American Psychiatric Association. DSM-5,
Social Communication Disorder. 2012. Available
at www.dsm5.org. Accessed March 6,
2013.

4. McPartland JC, Reichow B, Volkmar FR.
Sensitivity and specificity of proposed DSM-
5 diagnostic criteria for autism spectrum disorder.
J Am Acad Child Adolesc Psychiatry.
2012;51(4):368-383.

5. American Psychiatric Association. DSM-5
Development, Autism Spectrum Disorder.
2012. Available at: www.dsm5.org. Accessed
March 6, 2013.

6. Tanguay PE. Autism in DSM-5. Am J Psychiatry.
2011;168(11):1142-1144.

7. Ritvo ER. Postponing the proposed changes
in DSM-5 for autistic spectrum disorder until
new scientific evidence adequately supports
them. J Autism Dev Disord. 2012;42(9):2021-
2022.

8. Kanner L. Child Psychiatry. Springfield, IL:
Charles C. Thomas; 1935.

9. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders.
3rd ed. Washington, DC: American Psychiatric
Association; 1980.

10. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders.
DSM-III-R. Washington, DC: American
Psychiatric Association; 1987.

11. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders.
4th ed. Washington, DC: American Psychiatric
Association; 1994.

12. Lord C, Petkova E, Hus V, et alA multisite
study of the clinical diagnosis of different autism
spectrum disorders. Arch Gen Psychiatry.
2012;69(3):306-313.

13. Gibbs V, Aldridge F, Chandler F, Witzlsperger
E, Smith K. Brief Report: An Exploratory
Study Comparing Diagnostic Outcomes for
Autism Spectrum Disorders Under DSM-IV-
TR with the Proposed DSM-5 Revision. J Autism
Dev Disord. 2012;42(8):1750-1756.

14. Miller JN, Ozonoff S. The external validity of
Asperger disorder: lack of evidence from the
domain of neuropsychology. J Abnorm Psychol.
2000;109(2):227-238.

15. Gilchrist A, Green J, Cox A, Burton D, Rutter
M, Le Couteur A. Development and current
functioning in adolescents with Asperger syndrome:
a comparative study. J Child Psychol
Psychiatry. Feb 2001;42(2):227-240.

16. Howlin P. Outcome in high-functioning adults
with autism with and without early language
delays: implications for the differentiation between
autism and Asperger syndrome. J Autism
Dev Disord. Feb 2003;33(1):3-13.

17. Constantino JN, Hudziak JJ, Todd RD. Deficits
in reciprocal social behavior in male
twins: evidence for a genetically independent
domain of psychopathology. J Am Acad Child
Adolesc Psychiatry. 2003;42(4):458-467.

18. Constantino JN, Todd RD. Autistic traits in
the general population: a twin study. Arch
Gen Psychiatry. 2003;60(5):524-530.

19. Mattila ML, Kielinen M, Linna SL, et al. 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(6):583-
592.

20. Mandy WP, Charman T, Skuse DH. Testing
the construct validity of proposed criteria for
DSM-5 autism spectrum disorder. J Am Acad
Child Adolesc Psychiatry. 2012;51(1):41-50.

21. Frazier TW, Youngstrom EA, Speer L, et al.
Validation of proposed DSM-5 criteria for
autism spectrum disorder. J Am Acad Child
Adolesc Psychiatry. 2012;51(1):28-40.

22. Matson JL, Kozlowski AM, Hattier MA,
Horovitz M, Sipes M. DSM-IV vs DSM-5 diagnostic
criteria for toddlers with autism. Dev
Neurorehabil. 2012;15(3):185-190.

23. Matson JL, Hattier MA, Williams LW. How
Does Relaxing the Algorithm for Autism Affect
DSM-V Prevalence Rates? J Autism Dev
Disord. 2012;42(8):1549-1556.

24. 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(10):1056-1064.

25. Wing L, Gould J, Gillberg C. Autism spectrum
disorders in the DSM-V: better or
worse than the DSM-IV? Res Dev Disabil.
2011;32(2):768-773.

26. Constantino JN. How continua converge in
nature: cognition, social competence, and
autistic syndromes. J Am Acad Child Adolesc
Psychiatry. 2009;48(2):97-98.

27. Constantino JN, Lajonchere C, Lutz M, et al.
Autistic social impairment in the siblings of
children with pervasive developmental disorders.
Am J Psychiatry. 2006;163(2):294-296.

28. Frazier TW, Youngstrom EA, Sinclair L, et al.
Autism spectrum disorders as a qualitatively
distinct category from typical behavior in a
large, clinically ascertained sample. Assessment.
2010;17(3):308-320.

29. Amaral DG, Schumann CM, Nordahl CW.
Neuroanatomy of autism. Trend Neurosci.
2008;31(3):137-145.

30. Leventhal BL. Lumpers and splitters: who
knows? Who cares? J Am Acad Child Adolesc
Psychiatry. 2012;51(1):6-7.

31. Ozonoff S. Editorial: DSM-5 and autism
spectrum disorders - two decades of perspectives
from the JCPP. J Child Psychol Psychiatry.
Jul 16 2012.

32. Lord C, Jones RM. Annual research review:
re-thinking the classification of autism spectrum
disorders. J Child Psychol Psychiatry.
2012;53(5):490-509.

33. Taheri A, Perry A. Exploring the proposed
DSM-5 criteria in a clinical sample. J Autism
Dev Disord. 2012;42(9):1810-1817.