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Section 2: Diagnosis

2.1. DSM-5 Criteria for Autism Spectrum Disorders, 299.00 (F84.0)

A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 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 cause clinically significant impairment in social, occupation, or other important areas of current functioning.

'''E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequency co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.'''

2.2. Recommended Diagnostic Interview and Assessment
 * Autism Diagnostic Interview-Revised (ADI-R)5,14 – structured interview with parents of individual referred for ASD and measures behavior in the areas of reciprocal social interaction, communication and language, and patterns of behavior


 * Autism Diagnostic Observation Schedule-Generic (ADOS-G)6,12: consists of a series of structured and semi-structured tasks that involve social interaction between the examiner and the subject

Table 2. Areas Under the Curve (AUCs) and Likelihood Ratios for Potential Screening Measures for Autism Spectrum Disorders (ASDs)

LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation.

'''Section 4. Process and Outcome Measures'''

4.1. Table 3. Clinically Significant Change Benchmarks with Common Instruments

“A” = Away from the clinical range, “B” = Back into the nonclinical range, “C” = Closer to the nonclinical than clinical mean.

Note. ADI-R total scores: Comm-V Total=Communication Total for Verbal subjects; Comm-NV=Communication Total for Restricted, Repetitive Behavior Total. ADOS Module scores: Reported scores for Modules 1-3, Module 4 was not included and is typically used for higher-functioning adolescents and adults; SA=Social Affect Total; RR=Restricted, Repetitive Behavior Total. CARS: Clinician scores for typical sample were not reported.

* Negative cut scores may occur in the case when the minimum score on a measure (in this case, the ADOS-G domain RR) is 0.

Section 4.2. Process Measures: There are many processes that may be considered important when evaluating a child or an adolescent with ASD; however, due to the homogeneity of the population, there are too many to narrow down. Clinical judgment is recommended when deciding what additional measures should be included (e.g. executive functioning, sensory processing, cognitive flexibility). The two measures provided below are commonly used to assess adaptive behaviors (including communication and socialization, core deficits in ASD) and may provide important information regarding levels of daily functioning of individuals with ASD.


 * 4.2.a. Vineland Adaptive Behavior Scales (VABS)17,18 – Parent report recommended with careful attention paid to the Daily Living domain.


 * 4.2.b. Adaptive Behavior Assessment System (ABAS)19 – Special attention to the Global Adaptive Composite (GAC)