Difficulty engaging in smooth social-emotional interaction with non-ASD (allistic) peers.
eg. Nontraditional or intrusive forms of interaction.
May prefer purposeful and impersonal interactions.
Children may use an adult's hand to complete a task.
May have a hard time recognizing traditional physical or social boundaries.
eg. Difficulty with back-and-forth style conversations.
May not realize when more information is needed if not asked for.
May not realize when clarification is needed if not asked for.
May not respond when addressed.
May prefer to avoid casual conversation.
May prefer not to initiate conversations without need or prompting.
May enjoy sharing interests (special interests/SPINs).
May not think or speak in a traditionally linear way.
eg. Less sharing of interests and attention.
May avoid sharing interests with others without trust.
May be less interested in pointing at or calling out objects of interest to others.
May find joint attention difficult to engage in smoothly.
eg. Nontraditional expression of emotion.
May not smile in response to others' smiles.
May not express excitement in response to others' excitement in an expected way.
May respond uncertainty or unexpectedly to praise.
May not express enjoyment of social interactions in an expected way.
May struggle in offering comfort to others.
May find physical contact or physical affection uncomfortable.
eg. Limited social interaction.
May prefer to initiate social interaction with a purpose.
May express distaste for small talk.
eg. Difficulty with social imitation.
May not enjoy simple social games.
Difficulty interpreting or unexpected use of nonverbal communication.
eg. Difficulty or discomfort with eye contact.
May find eye contact uncomfortable and struggle to maintain it when expected.
May hold eye contact longer or more intensely than expected.
eg. Difficulty interpreting or unexpected use of body language.
May express socially "disrespectful" body language without the intention of being impolite.
May struggle to interpret others' body language.
May favor direct or specific verbal communication over the vaguity of body language.
eg. Difficulty interpreting or unexpected use of facial expressions.
May not express emotions facially.
May show facial expressions which do not match their emotions.
May show exaggerated facial expressions.
May struggle to interpret others' facial expressions.
eg. Difficulty interpreting or unexpected use of gestures (eg. pointing, waving, nodding/shaking head).
May not use gestures in conversation, possibly relying more on words.
May not look at or struggle to interpret others' gestures.
eg. Under-regulated or nontraditional speech patterns.
May experience difficulty controlling volume of speech.
May speak with an atypically high or low pitch.
May struggle to communicate with intonation (rise and fall of speech), especially flat speech.
May speak unusually quickly or slowly.
May speak with unusual prosody (rhythm, stress, and intonation), especially in a lyrical manner.
eg. Unexpected use of affect or difficulty interpreting affect.
May not maintain a traditionally friendly facial expression around others.
May not express their own emotion in a socially expected way.
May struggle to interpret others' nonverbal expressions of emotion.
eg. Discoördinated verbal and nonverbal communication.
May not coordinate eye contact or body language with words.
May shift, move, or fidget while conversing, possibly as a way to regulate focus or attention.
eg. Discoördinated nonverbal communications.
May not coordinate eye contact with gestures.
Difficulty with or disinterest in developing and maintaining traditional relationships.
eg. Difficulty or uncertainty in predicting others' thoughts, emotions, or desires (theory of mind).
May struggle or feel uncertain with taking another person's perspective.
May struggle or feel uncertain with predicting how others will act or respond.
eg. Difficulty adjusting behavior to social context expectedly.
May struggle to interpret if others are interested in a topic or not.
May not respond or respond unexpectedly to social queues.
May struggle to know what behaviors are socially appropriate in different contexts.
May struggle with social conventions/appropriate social behavior.
May struggle to recognize when a question or statement is or is not socially appropriate.
May not notice or have difficulty interpreting others' distress or disinterest.
May not notice or have difficulty interpreting when they are welcome or not welcome.
eg. Difficulty with or disinterest in shared imaginative play.
May prefer to play alongside peers rather than engaging with them (parallel play).
eg. Difficulty with or disinterest in making friends with non-autistic (allistic) peers.
May not reach out to establish friendships.
May not have or struggle to pick out preferred friends.
May be unaware when teased or ridiculed.
May struggle to relate their actions to their impact on others' emotions.
May favor individual or small-group work/activities over group work/activities.
May prefer interacting with younger or older individuals over peers.
May struggle with traditional social conventions (eg. may be overly commanding, rigid, or passive).
May be unresponsive to or unaware of peers attempting to engage or become friends.
eg. Disinterest in social interaction.
May be uninterested in their peers.
May prefer their own thoughts or passions over social interactions.
May avoid or not try to attract the attention of others.
May have limited interest in others.
May be unaware or oblivious of children or of adults.
May prefer solitary activities.
Stereotyped or repetitive behaviors (stereotypies/stims/self-stimulatory behaviors).
eg. Stereotyped or repetitive patterns of speech.
May prefer to speak or express themselves unexpectedly formally or pedantically.
May find stimulation in repeating words/phrases/quotes/lyrics they have heard or read, either immediately or unprompted (echolalia).
May respond to questions by repeating [part of] the question, possibly to help structure a response.
May find stimulation in ‘jargon’ or gibberish.
May pre-plan conversations or express themselves using memorized language or quotes, possibly to help structure interactions.
May frequently express themselves using inside jokes or terms they invent themselves.
May reverse pronouns in speech (eg. swapping the use of "I" and "you").
May refer to themselves by their name rather than using "I."
May repeat themselves unprompted, possibly due to a temporary fixation on a topic or idea (perseveration).
May find stimulation in repetitive vocalizations (stereotypies/stims/self-stimulatory behaviors).
eg. Stereotyped or repetitive motor movements.
May find stimulation in repetitive hand movements (stereotypies/stims/self-stimulatory behaviors).
May find stimulation in stereotyped or complex whole body movements (stereotypies/stims/self-stimulatory behaviors).
May show unexpected posture (eg. walking on toes, heels, or edge of feet; unusual full body posturing; 'raptor hands').
May find stimulation in tensing or relaxing their body (incl. whole body, face, jaw, etc.).
May repetitively puts hands over ears.
May find stimulation from picking at their body repetitively.
May prefer to continuously repeat a favored activity/behavior/game.
eg. Stereotyped or repetitive use of objects.
May play with objects or toys in unexpected or nontraditional ways.
May enjoy lining up or organizing toys as much as or more than imaginative play with them.
May find stimulation in manipulating kinetic or mechanical objects (eg. opening and closing doors or flipping light switches).
Insecurity from the unexpected or unfamiliar.
eg. Finds security in routine.
May find comfort in or feel a strong need to maintain established routines (excluding bedtime routines unless components or level of adherence is atypical).
May follow unusual routines.
eg. Finds security in ritualized patterns of behavior.
May ask repetitive questions or prefer to stick to familiar topics when interacting with another person.
May feel uncomfortable with unexpected interactions or unfamiliar paths of conversation.
May experience compulsions.
eg. Finds security in stability.
May struggle to transition to a new situation or focus unexpectedly.
May react strongly to relatively minor unexpected changes.
May have a distaste for certain foods which do not have consistent quality.
eg. Different patterns of processing and thinking.
May experience a different sense of humor than their peers.
May struggle to understand non literal or explicit aspects of speech such as irony, sarcasm, or implied meaning.
Highly passionate focus on specific subjects (special interests/SPINs).
eg. Preoccupations/obsessions.
eg. Highly passionate or focused interests.
eg. Very select interests or subjects of focus.
eg. Fascination with numbers/letters/symbols.
eg. Desire for perfectionism.
eg. Focus or interest in unexpected aspects of objects.
eg. Experience of preoccupations/fascinations.
eg. Attachment to or personification of everyday objects (not just expected objects like plushies).
eg. Unusual fears.
Sensory processing issues.
eg. Unusually high or low tolerance for pain.
eg. Seeks or avoids stimulation from pressure.
May press on eyes.
May seek out hugs or tight spaces.
eg. Seeks or avoids stimulation from texture or touch.
May seek out the feel of certain textures or objects (understimulation).
May be averse towards the feel of certain textures or objects, possibly because they are overwhelming (overstimulation).
May dislike being touched by certain objects.
May show significant aversion to having hair or toenails cut or teeth brushed.
May have a distaste for certain foods due to the sensation of the food's texture.
eg. Seeks or avoids stimulation from light or visual activity.
May seek out the sensation of certain visual activity (understimulation).
May be averse towards the sensation of certain visual activity or lighting, possibly because they are overwhelming (overstimulation).
May become overwhelmed by the sensation of bright lighting or vibrant colors.
May show fascination with watching things move, especially organic or mechanical movement.
May inspect objects closely or at unexpected angles.
eg. Seeks or avoids stimulation from sound.
May seek out the sensation of certain sounds or rhythms (understimulation).
May be averse towards the sensation of certain sounds or rhythms, possibly because they are overwhelming (overstimulation).
eg. Seeks or avoids stimulation from smell or taste.
May seek out the sensation of certain smells or tastes (understimulation).
May be averse towards the sensation of certain smells or tastes, possibly because they are overwhelming (overstimulation).
May have a distaste for certain foods due to the sensation of the food's smell or taste.
eg. Seeks or avoids stimulation from movement or balance.
May seek out the sensation of certain motions (understimulation).
May be averse towards the sensation of certain motions, possibly because they are overwhelming (overstimulation).
eg. Responds unexpectedly to sensory input.
eg. Explores things in unexpected ways.
May explore broader sensory aspects than expected, such as licking or sniffing objects.
Social Communication Severity (criterion A)
Requiring very substantial support (level 3)
Severe struggles with verbal and nonverbal communication.
Very limited initiation of social interaction and minimal response to others' approaches.
Requiring substantial support (level 2)
Marked struggles in verbal and nonverbal communication are noticeable even with supports.
Limited initiation of social interaction and reduced or abnormal response to others' approaches.
Requiring support (level 1)
Struggles with social communication are noticeable without supports.
Struggles to initiate social interaction and shows atypical or unsuccessful response to others' approaches.
Restricted, Repetitive Behaviors Severity (criterion B)
Requiring very substantial support (level 3)
Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres.
Shows great distress while changing focus or action.
Requiring substantial support (level 2)
Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors are obvious to casual observers and interfere with functioning in several spheres.
Shows distress or difficulty changing focus or action.
Requiring support (level 1)
Inflexibility of behavior causes notable interference with functioning in one or more contexts.
Shows difficulty switching between activities.
Struggles with organization and planning enough to hamper independence.
With or Without Comorbid Intellectual Disability
With or Without Comorbid Language Disorder
Associated with Known Medical/Genetic/Environmental Factor
With or Without Comorbid Neurodevelopmental/Behavioral Disorder
With or Without Comorbid Catatonia
General intellectual functioning decrements may be mistaken for ASD.
(World Health Organization, 2022)Difficulty with pragmatic language may be mistaken for ASD's social communication deficits.
(World Health Organization, 2022)Poor motor praxis may be mistaken for a lack of interest in sports or motor activity rooted in ASD.
(World Health Organization, 2022)Inattention, restlessness/hyperactivity, and impulsivity, especially in social situations, may be mistaken for ASD.
(World Health Organization, 2022)Stereotypies by themselves may be mistaken for ASD's restricted and repetitive behaviors.
(World Health Organization, 2022)Social withdrawal, restricted and repetitive behaviors and interests, and inflexibility may be mistaken for ASD.
(World Health Organization, 2022)Fear or anxiety when in unfamiliar social situations may be mistaken for ASD's communication deficits.
(World Health Organization, 2022)A lack of verbal language use in specific environments or situations may be mistaken for ASD's communication deficits.
(World Health Organization, 2022)Compulsions performed to relieve the anxieties of obsessions may be mistaken for ASD's restricted and repetitive interests and behaviors.
(World Health Organization, 2022)Withdrawn behavior towards caretakers due to social deprivation or social deficits and restricted and repetitive behaviors and interests which diminish when moved to a healthy environment may be mistaken for ASD.
(World Health Organization, 2022)Uninhibited social approaches due to social deprivation may be mistaken for ASD.
(World Health Organization, 2022)Specific or restricted food intake may be mistaken for ASD's adherence to routines or unusual sensory responses.
(World Health Organization, 2022)Oppositional or defiant behaviors may be mistaken for ASD outbursts or meltdowns.
(World Health Organization, 2022)Tics may be mistaken for ASD's stereotyped movements (stims).
(World Health Organization, 2022)Tics are less rhythmic (stereotyped), shorter in duration, uncomfortable, and are usually preceded by a premonitory sensory urge
International Classification of Diseases, Eleventh Revision (ICD-11), World Health Organization (WHO) 2019/2021 https://icd.who.int/browse11. Licensed under Creative Commons Attribution-NoDerivatives 3.0 IGO licence (CC BY-ND 3.0 IGO).
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Center for Disease Control and Prevention. (2022, April 6). Autism spectrum disorder (ASD): Diagnostic criteria. https://www.cdc.gov/ncbddd/autism/hcp-dsm.html