DSM-5 autism criteria in plain language

What the DSM-5-TR is

The Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association, is the main reference US clinicians use to diagnose autism. The fifth edition in 2013 brought several earlier diagnoses, including Asperger's syndrome, under a single autism spectrum disorder diagnosis. A text revision, DSM-5-TR, followed in 2022 with clarifications. Below we summarize the criteria in our own words. Only a qualified clinician can apply them.

Area 1: Social communication and interaction

The first area covers persistent differences in how a person communicates and connects with others, across different settings. The manual describes three parts, and all three must be present now or in the person's history:

• Differences in social and emotional back and forth. For an adult, this might look like conversations that become one-sided monologues, trouble knowing how to start or end a chat, or uncertainty about sharing feelings in the expected way.
• Differences in nonverbal communication. Examples include eye contact that feels unnatural or is avoided, facial expressions or tone of voice that others misread, or difficulty interpreting other people's gestures and expressions.
• Differences in developing, keeping and understanding relationships. This can mean finding it hard to adjust behavior to different social settings, struggling to make or keep friends, or preferring solitary activities, while still wanting connection.

Area 2: Restricted and repetitive patterns

The second area covers repetitive or restricted patterns in behavior, interests or activities. At least two of four types must be present now or in the past:

• Repetitive movements, speech or use of objects. In adults this may be rocking, tapping, repeating phrases from shows or conversations, or arranging objects in a precise way.
• Strong need for sameness and routine. Examples include distress over small changes, eating the same foods, taking the same route, or needing a set ritual before leaving the house.
• Highly focused interests that are unusually intense or narrow. An adult might spend years mastering a specific topic, from train timetables to a fictional universe, with depth others find surprising.
• Sensory differences. This includes being over- or under-sensitive to sound, light, touch, smell, taste or pain, or seeking out particular sensations.

Early development, masking and late recognition

The manual requires that signs were present in the early developmental period. It also recognizes two things that matter enormously for adults. First, differences may not fully show until social demands exceed what a person can manage, for example at secondary school, college, a first job or parenthood. Second, differences may be hidden by strategies the person has learned, which is the clinical acknowledgment of masking.

Significant impact on daily life

The differences must cause clinically significant difficulty in social, work or other important areas of life. For adults, this might show up as repeated job loss after social conflicts, burnout from constant masking, isolation, or struggling with daily tasks under sensory overload. Traits alone, without meaningful impact, are not enough for a diagnosis.

Not better explained by intellectual disability

The final condition is that the differences are not better explained by intellectual disability or global developmental delay. The two can co-occur, and both can be diagnosed together when social communication is below what would be expected for the person's general developmental level.

Specifiers clinicians add

When making a diagnosis, clinicians also note details such as whether there is accompanying intellectual impairment, accompanying language impairment, a known genetic or medical condition, or another neurodevelopmental or mental health condition, and a level of support needed for each of the two core areas.

• Autism levels 1, 2 and 3 explainedAutism levels 1, 2 and 3 explained: what DSM-5 support levels describe, how clinicians assign them, why they are criticized, and why no quiz gives one.

How ICD-11 compares

Much of the world uses the World Health Organization's ICD-11, where autism spectrum disorder is coded 6A02. Its description closely mirrors the DSM-5-TR's two core areas, but instead of support levels it uses subcategories based on intellectual development and functional language.

What the criteria do not mean

• They are not a checklist you can score at home. Clinicians use judgment, history and observation.
• Meeting some descriptions in isolation does not mean a person is autistic.
• Strong language skills, a job or relationships do not rule out autism.
• Different autistic adults can meet the criteria in very different ways.