Examinations of ASD require a fundamental explanation both of the disorder and its classifications. The DSM-5 overhauled the classification of Autism and Asperger’s from the DSM-5. They list the diagnostic criteria of ASD as follows. We will look at each passage to discuss the pragmatic representation of these abilities that I have experienced in clinical settings.

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text):

In short, this must be present. I must see, as a clinician, a developmental shortcoming in social communication and interaction. It must be across contexts or situations. For example, you must have this problem with social communication and interaction in school, at home, on the playground, at work, and at the dinner table.

It cannot be that you choose not to talk at a certain time, that you don’t like someone so you refuse interaction, or that you have a biological condition.

The first step of any diagnosis is that I must rule out an organic, biological, or medication cause. I must also rule out other diagnoses such as schizophrenia. This is done in a long interview where I meet with the client/person in a face-to-face setting for 2 hours to do a biopsychosocial assessment that assesses problems from multiple angles.

Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

This is an example behavior. Typically in those with autism, this is hallmark. I will see a marked problem with social-emotional reciprocity. That is, they will have difficulty reading and returning emotions. I often also see this represented in facial expressions which are often very “flat”. There may not be smiles, frowns, etc. as these are all social cues.

Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures: to a total lack of facial expressions and nonverbal communication.

This is another example and it is, again, hallmark. This is an example of the exact same behavior as you see above. However, this example is much more clued in on the non-verbal. The prior example was keyed to verbal or contextual information of speech, communication, and linguistics.

Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

This is also hallmark. I see this in almost every person with ASD. This speaks to behaviors and relationships that result from behaviors. Most often, I’ll see a large absence of interest in select peers who do not interest the person with ASD. They may like the person, but they do not show interest in them. Those with ASD are not selfish. They are not self-absorbed. They simply show interest when interest is present. If interest is not present, interest will not be expressed.

After all, it’s simply polite to pretend that you’re interested in someone while simultaneously tuning them out. This is a social skill.

What the DSM-5 did here in this area is remove the concept of Autism as a checklist of behaviors. Instead, the DSM-5 allowed for room for clinical judgment. Those who do not know differential diagnosis believe that mental health should be something that is delineated.

However, the reality of human behavior is that it happens on a continuum. No behavior if categorical. You don’t just feel depressed. You have a wide range of behaviors, expressions, and precipitating factors of depression. Continuum diagnosis allows for this continuum of human behavior expressions based upon a whole multitude of variables including age, height, weight, socioeconomic status, early intervention, race, gender, sexuality, and any other variable that makes one person different from another. Yes, even hair color can affect the expression of a certain disorder. After all, those with red hair may express anxiety due to social disapproval based on recessive genes.

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):

This is the second required area of ASD. I must see some sort of restricted, repetitive pattern of behavior, interest, or activities. These do not have to range from simple to complex. They merely have to be restricted (that is fixated or bound to a certain thing) and repetitive.

If someone must play video games on a certain time at a certain place with a certain game, this qualifies.

This is different from Obsessive-Compulsive Disorder as these rituals lack obsession. Obsessions are intrusive and unwanted. Compulsions are demands that you carry them out to alleviate the intrusive, unwanted thought. Upon carrying out the action, the person feels a stress release that reinforces the ritual.

ASD stereotypy and ritualism are not intrusive and unwanted. They are fixations and preoccupations, but they are not intrusive and unwanted. They present no distress, and doing the behavior does not release from stress. The behaviors may self-soothe and relax, but the thoughts of the behavior do not cause distress that is then released by action.

Below are some of the example behaviors of this requirement:

Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

I tend to see this in many persons with ASD. Often times, these behaviors are self-soothing. I tend to see rocking in those with ASD. Sometimes, I’ll see idiosyncratic behaviors such as tapping of the hand with fingers. These behaviors may self-soothe, but the intent of them is not to release stress. Often, they’re intended to reinforce an attempt at homeostasis through stimuli that are familiar.

In other words, if you’re experiencing something you don’t like (a screaming child), your response will be to do something you DO like (leaving the room). The response is the same, but it’s often nonverbal and behavioral instead of verbal due to potential language delay

Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).

I see this manifestation in nearly every person with ASD that I’ve ever treated. The disruption to familiar schedules is absolutely devastating. It can literally destroy an entire day. If there is a change to the schedule that is expected, any disruption to that expected schedule will obliterate the entire day.

This can also appear like OCD, but note that the requirement of the ritual is not based in stress and catharsis. It’s based in familiarity of ritual and schedule along with the preference to adhering to the schedule.

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

I see this one very regularly as well. Interests will typically be very specific and they will be rigid. For example, someone with ASD may develop an interest in Pokemon. They will then collect every Pokemon game, buy every Pokemon card, get every Pokemon plushie, but every Pokemon side item, watch every Pokemon TV show, and generally appear like a “creepy Pokemon fan.”

However, they are just fixated upon Pokemon. It holds their interest, and what holds their interest is worth pursuing. Do note that interests can change. However, it must be on the schedule of the person with ASD. Change that is rooted in the desire of another person is a violation of ritual.

Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse re­ sponse to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

I tend to see this one in nearly every single client/person with ASD. I generally see more hypereactivity than I see hyporeactivity. This is the classic example of those with ASD. They cannot block out stimulus. Everything floods in.

It is incredibly painful when it happens.

The response to this event is typically an activation of the sympathetic nervous system located in the amygdalae in the limbic system in the medial temporal lobes. In short, the amygdalae are little almonds with tubes that sit not too far behind your eyes. This structure is responsible for emotion, some memories, and decision-making.

When you experience stress of any kind, the amygdalae make a decision and send out a signal to fight or run to the brain. The brain then sends out, from the motor cortex, the behavior that is desired. Along the way, the brain sends out the signal to activate the sympathetic nervous system to do any of this. Your body then sends out adrenals and a signal shoots from your brain to the rest of your body to either fight the stress or run.

Now imagine you have no clue what the hell just happened to your body when all of this happened. You’re a young kid who just experienced this overload, you’re in pain, and your body is sending you this weird signal to run or fight.

The response of many with ASD from this hypereactivity is to develop specific behaviors, reactions, or activities that keep this chain reaction from happening. If it gets bad enough, someone with ASD may accept any similar stimulus over the unfamiliar one. Sometimes, this means hitting yourself in the head until you bleed because what is happening in your brain is so painful (overstimulation) that the response is to replace it with something you know.

The behaviors that you know and that keep you calm are self-soothing. The ASD community sometimes call these behaviors “stimming.”

Stimming is not, as a word, a diagnostic term. Professionals use the term stereotypy, ritualized, or stereotyped. Stimming is a term adopted by the ASD community to dispel a perceived stigma of stereotyped or ritualized. Stereotype, for example, can mean a negative belief structure of someone. Ritualization can, for example, mean a set of behaviors that are required for participation.

The psychiatric field uses neither term in that manner.

C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).

We previously stuck to diagnosing ASD in childhood. The DSM-IV-TR allowed for Pervasive Developmental Disorder NOS (not otherwise specified) for adult diagnoses. However, I rarely diagnose ASD as developed in adulthood. Typically, the diagnosis is historic and reproduced in multiple forms of treatments prior to reaching me.

D. Symptoms cause clinically significant impairment in social, occupational, or other im­portant areas of current functioning.

This is standard for every single disorder. I cannot, as a professional, diagnose someone who does not have clinical significance in the domain of social, occupational, or other areas of functioning.

If someone as ASD and they are functioning well, I cannot diagnose it. In fact, if someone has a schizophrenia or a bipolar disorder, I cannot diagnose it if there’s not impairment. However, those who come to my clinic are typically there because there’s impairment.

This is where there’s a fundamental difference between laypersons, undergraduates, non-licensed people, and anyone else who likes to use the DSM for self-diagnosis. Professionals are keenly aware of the requirement on every disorder for impairment in some setting of life.

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

This is crucial. Some expressions of ASD may actually be because of intellectual functioning and disability. I typically request an IQ test on a new diagnosis of ASD. I need to know that the functional state is not better explained by intellectual disability. I also must know that it’s not better explained by a biological or medical condition. For example, Broca’s aphasia (a piece of the brain causes a loss in the ability to produce speech) may better explain ASD symptoms of not communicating or doing so poorly with a limited vocabulary.

Finally, a note:

Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.

The DSM-5 created a new diagnosis for those who simply have problems with pragmatic speech. This means issues with speech on a social level. This diagnosis is meant to separate those who may just have problems communicating socially from those who have ASD. So for those who may have problems with social communication but have no stereotypy, hyperstimulation, developmental delays outside of speech, inflexibility, etc may qualify for pragmatic communication disorder under the DSM-5.

Diagnostically, we must look for impairment in social communication and interaction, restricted types of behaviors, and an early childhood onset. There must be impairment. We can also accept historic reports of ASD.

We cannot accept self-diagnosis or anecdote in lieu of professional assessment.

One reason for this is a principle in psychiatry known as insight. Insight is the concept that the person who presents knows the causes and effects of the disorder. Typically speaking, most of those I see with ASD have poor insight into the causes of ASD.

Many of those who experience ASD are well aware of the effects of ASD, however. They know the experience of ASD. They know what it feels like, smells like, tastes like, and how it affects their life. This is the case for every disorder. The effects and treatments of the disorder are understood well before the causes.

For this reason, experience of a disorder in effects is not acceptable for explanation of disorder in cause. Even if someone has full insight into the disorder, they still are not qualified to assess, diagnose, and treat that disorder. They are not governed by an ethics board, licensed by a legal board in their state, and they are not educated in the execution of treatment.

Another reason is something called differential diagnosis. You may hear this on television, but differential diagnosis requires having a vast knowledge base of every single disorder in the DSM. It requires being keenly oriented to parsing out difficult information that may not be presented clearly by someone who cannot communicate clearly for whatever reason.

Having a license means that you have the experience, knowledge, and background. You have the training. You have the base from which to draw for a vast diversity of expressions of ASD or any other disorder.

We are educated, trained, and licensed to handle any behavior, thought, or feeling that someone with ASD (or those without) reports. This was done over 2 years of education, 2 years of training, and years of practice with adults who have a wide array of behaviors, thoughts, feelings, and expressions of behaviors.

MHPs know a large amount of treatments, and we are keenly aware of both the benefits and the risks of those treatments. We weigh them against the needs of my client, their family, greater society, and we implement a treatment plan accordingly in keeping with my state’s laws and regulations, the laws and regulations of insurance companies, and the expectations of all involved.

Experiencing ASD or any other disorder does not prepare any particular person for negotiating this incredibly rocky terrain. In fact, treatments for ASD could cause someone’s suicide. It could cause someone’s death. It could cause families to break up. It could cause someone to hurt themselves.

Therapists are trained, licensed, and insured to do any of this. Someone who experiences a disorder is not. This increases their liability based upon limited insight, knowledge, and expertise in this area.

Much in this same vein, someone with a heart murmur is not qualified to do open-heart surgery on others. Mental health is just as delicate. People can, and do, die if mental health procedures and interventions are done incorrectly.

Every therapist has a story of at least one client that said, “I’m OK,” left the office, and killed themselves. Therapists are equipped to handle that in full.