New DSM-5 includes changes to autism criteria
- Copyright © 2013, The American Academy of Pediatrics
- Susan L. Hyman, M.D., FAAP
The American Psychiatric Association has just published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The diagnostic criteria for autism spectrum disorder has been modified based on the research literature and clinical experience in the 19 years since the DSM-IV was published in 1994.
The diagnosis will be called Autism Spectrum Disorder (ASD), and there no longer will be subdiagnoses (Autistic Disorder, Asperger Syndrome, Pervasive Developmental Disorder Not Otherwise Specified, Disintegrative Disorder).
In DSM-IV, symptoms were divided into three areas (social reciprocity, communicative intent, restricted and repetitive behaviors). The new diagnostic criteria have been rearranged into two areas: 1) social communication/interaction, and 2) restricted and repetitive behaviors. The diagnosis will be based on symptoms, currently or by history, in these two areas.
Although symptoms must begin in early childhood, they may not be recognized fully until social demands exceed capacity. As in the DSM-IV, symptoms must cause functional impairment.
All of the following symptoms describing persistent deficits in social communication/interaction across contexts, not accounted for by general developmental delays, must be met:
Problems reciprocating social or emotional interaction, including difficulty establishing or maintaining back-and-forth conversations and interactions, inability to initiate an interaction, and problems with shared attention or sharing of emotions and interests with others.
Severe problems maintaining relationships — ranges from lack of interest in other people to difficulties in pretend play and engaging in age-appropriate social activities, and problems adjusting to different social expectations.
Nonverbal communication problems such as abnormal eye contact, posture, facial expressions, tone of voice and gestures, as well as an inability to understand these.
Two of the four symptoms related to restricted and repetitive behavior need to be present:
Stereotyped or repetitive speech, motor movements or use of objects.
Excessive adherence to routines, ritualized patters of verbal or nonverbal behavior, or excessive resistance to change.
Highly restricted interests that are abnormal in intensity or focus.
Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of the environment.
Symptoms must be present in early childhood but may not become fully manifest until social demands exceed capacities. Symptoms need to be functionally impairing and not better described by another DSM-5 diagnosis.
Symptom severity for each of the two areas of diagnostic criteria is now defined. It is based on the level of support required for those symptoms and reflects the impact of co-occurring specifiers such as intellectual disabilities, language impairment, medical diagnoses and other behavioral health diagnoses.
Rett syndrome is a discrete neurologic disorder and is not a subdiagnosis under ASD, although patients with Rett syndrome may have ASD.
Because almost all children with DSM-IV confirmed autistic disorder or Asperger syndrome also meet diagnostic criteria under DSM-5, re-diagnosis is not necessary. Referral for reassessment should be based on clinical concern. Children given a PDD-NOS diagnosis who had few DSM-IV symptoms of autism or who were given the diagnosis as a “placeholder” might be considered for more specific diagnostic evaluation.
Patients may wish to continue to self identify as having Asperger syndrome, although the DSM-5 diagnostic category will be ASD.
Clinicians should note that children with ASD also should be evaluated for a speech and language diagnosis in addition to the ASD to inform appropriate therapy.
The DSM-5 includes a new diagnostic category of social communication disorder that describes children with social difficulty and pragmatic language differences that impact comprehension, production and awareness in conversation that is not caused by delayed cognition or other language delays.
Coding and billing
Because the new DSM-5 criteria combine all previous subdiagnoses under one condition (ASD), there may be inconsistency between billing databases and DSM-5 diagnoses. Both ICD-9-CM and ICD-10-CM contain specific codes for subdiagnoses, including Asperger’s.
Therefore, it is recommended that services provided for children with autism spectrum disorders are reported with codes such as ICD-9-CM code 299.00 or 299.01. On or after Oct. 1, 2014, report ICD-10-CM code F84.0.
In summary, pediatricians should counsel parents whose children had a diagnosis of an autism spectrum disorder made using DSM-IV criteria that they do not need to be reevaluated for diagnosis with the publication of DSM-5. No change in educational or therapeutic programming is indicated for children and youths carrying the diagnosis of an ASD relative to the publication of the DSM-5.
Additional information and resources on autism spectrum disorders for pediatricians and families can be found at www.medicalhomeinfo.org/about/cocwd/autism.aspx.
Coding inquiries can be directed to the AAP Coding Hotline at.
Dr. Hyman is chair of the AAP Council on Children with Disabilities Autism Subcommittee.